Introduction

The COVID-19 pandemic introduced extreme burden to health systems globally1, highlighting the need for all countries to strengthen the health information technology infrastructure. Telehealth2, which employs telecommunications and virtual technologies to deliver care outside of traditional clinical settings, has been proven to be effective in improving healthcare delivery, including patients triage3, consultation4, treatment5, clinical care6, and education of healthcare workers and patients7.

The pandemic has even more severe impacts on developing countries or low- and middle-income countries (LMICs) due to the limited medical resources and constrained economic situations8,9. According to the World Bank, LMICs are defined as economies with a gross national income (GNI) per capita less than $12,535 in 202010. China, the largest developing country, has made significant strides in integrating rural and urban areas, agriculture, and industry into cohesive networks of capital, labor, and commodities in the past decades10. Despite these efforts, spatial separation, economic disparities, and differences in social service provision have contributed to persistent rural-urban inequalities11. In 2020, the rural population in China was reported to be 38.57% of the total population12. Despite the increased investment in healthcare and several major healthcare reforms in China, the rural-urban divide in healthcare resource distribution and health outcomes continues to widen13,14,15. This disparity poses an even larger threat during the COVID-19 pandemic, as timely and high-quality healthcare service is crucial for vulnerable populations in rural areas16.

Although previous studies of telehealth implementation in developed countries or high-income countries provide some useful implications, the telehealth systems were often built upon established technological infrastructure with sufficient economic support, well-trained workforces, and target user populations with higher digital literacy17,18. These lessons and implications may not be applicable to developing countries or LMICs, where infrastructure is less established, and resources (medical, financial, technological, and human) are limited and unevenly distributed. Therefore, it becomes imperative to understand and share sustainable and scalable strategies for implementing and adopting telehealth systems in developing countries or LMICs. This systematic review aims to comprehensively summarize the characteristics, barriers, and successful experiences in implementing telehealth services in China during the COVID-19 pandemic. This systematic review has three contributions: (1) It offers an in-depth exploration of a specific country, providing detailed insights into the characteristics of telehealth implementation within that particular context; (2) by applying the lens of implementation science, the review synthesizes the findings and offers practical strategies that can be adapted to developing countries or LMICs with varying levels of economic development; (3) providing specific recommendations for building telehealth systems, including guidance on infrastructure and mechanisms, which may be useful to other developing countries or LMICs looking to develop their own telehealth capabilities.

Methods

This systematic review follows the latest version of the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guideline for identifying potentially related articles19. The protocol for this systematic review was available at PROSPERO (CRD42023402844)20.

Data Sources and Search Strategy

A comprehensive search was conducted across five databases: PubMed/MEDLINE, Embase, Scopus, Cochrane Library, and Web of Science, for articles published until the end of June 2022. The search terms were prepared using the PICOS approach, which stands for patients, problem or population (P), issue of interest or intervention (I), comparison, control or comparator (C), outcome (O), and study type (S). To ensure the search’s comprehensiveness and relevance to the research questions, three domains were used to construct the search strategy: COVID-19, telehealth, and China. Studies that were conducted in Hong Kong and Macau were not included because they were developed economies. A combination of keywords and controlled vocabulary terms related to the target concepts was utilized. The search strategy was designed and developed by two authors (JY and LH) independently. To validate the search strategies, an experienced librarian (MB) reviewed and confirmed them. The search strategies for each of the databases were demonstrated in Supplemental Table 1.

Eligibility criteria

We used the following PICOTS (Population, Intervention, Comparator, Outcomes, Time course, and Study design) elements to build eligibility criteria for the included studies:

Population: Any patients

Intervention

Studies that evaluated the effect of any intervention, including system- and provider-level implementation strategies as well as patient behaviors, aimed at adopting telehealth services. We included trials that tested interventions targeting:

  • Health Systems: health insurance policy; strengthening infrastructure, health system financing, and other incentives (e.g., reimbursement); regulation and governance; and other management techniques.

  • Clinicians: education; group problem solving; health care provider-directed financial incentives; supervision; high-intensity or low-intensity training; information and communication technology for health care providers.

  • Patients: patient education; insurance and employment improvement; and promotion of self-management (e.g., behavioral and motivational interventions).

Comparator

We considered any standard or usual care as the control group.

Outcomes

The primary effectiveness outcome was:

  • Effectiveness between telehealth and control groups.

Secondary effectiveness outcomes were:

  • Cost of intervention.

  • Cost-effectiveness.

Study design

We included experimental (e.g., randomized methods of assignment) and quasi-experimental (e.g., non-randomized methods of assignment) trials and studies using other experimental designs (e.g., controlled before–after studies or interrupted time series). Exclusion criteria based on study design were observational studies (e.g., prospective/retrospective cohort studies); cross-sectional and case–control studies; and opinion-driven reports (e.g., editorials, letters, and non-systematic or narrative reviews).

Study selection

The inclusion criteria for this systematic review included (1) studies that utilized telehealth or telemedicine platforms for activities such as screening, triage, prevention, diagnosis, treatment, or follow-up of patients, irrespective of their health conditions, during the COVID-19 pandemic; (2) the review encompassed a broad range of sources, including journals, conferences, scientific guidelines, and case reports, focusing on studies involving human participants with access to the full text (without requiring free article access); (3) studies conducted in either English or Chinese language.

The exclusion criteria for this systematic review included (1) studies that lacked full-text availability; (2) studies that solely assessed participants’ attitudes toward telehealth services without presenting any tangible evidence or results related to the deployment of telehealth platforms or services; (3) studies that used telehealth tools to collect data for testing research hypotheses with no immediate and direct benefits for patients or health care providers; (4) studies that failed to describe any specific telehealth or telemedicine platform, service, or tools used in their research.

Screening and eliminating irrelevant sources

First, duplicate articles were eliminated from the retrieved articles. Then, JY and LH independently screened articles based on titles and abstracts to identify the studies that potentially could fit into the research question and met the eligibility criteria. An article would be excluded if it was marked irrelevant by two of the reviewers. In cases where the decision couldn’t be made based on the title or abstract alone, the full text was thoroughly examined. In instances of disagreement, the authors held multiple meetings to resolve any discrepancies and achieve a consensus.

Data extraction

A comprehensive data extraction form was developed to gather general and technical information from the included studies. For each included study, the first author’s name, publication year, research location (city/region), health care system/hospitals, diseases, platforms, outcomes, services, telehealth infrastructure, barriers/challenges, successful experiences, and recommendations were extracted.

Regarding the service type, we considered ten categories, as shown in Table 1. We extracted and categorized challenges and significant barriers from the literature, based on specific topics. The research team members collaborated to reach a consensus, grouping similar topics under relevant categories and assigning appropriate terms to each category based on its theme.

Table 1 Purpose of telehealth use during the COVID-19 pandemic.
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Data synthesis and analysis

The data analysis commenced with an overview of the study and a comprehensive examination of the telehealth system properties, with the extracted data presented in a tabulated format. For articles published in Chinese, the two authors (JY and LH) translated the data into English and engaged in detailed discussions about the information. Simultaneously, the data were systematically categorized to encompass a wide range of values for each variable. We then refined the categories by introducing new ones and consolidating or omitting older versions, persisting until no further new categories emerged, ensuring a robust classification system.

A narrative synthesis was employed to articulate the reported results of the studies. The data obtained were qualitatively elaborated and thoughtfully presented. During the qualitative synthesis, the two reviewers (JY and LH) collaborated closely to identify preliminary themes. Themes that lacked sufficient representation in the data were removed, and similar themes were combined to enhance clarity and cohesiveness21.

Framework

The Consolidated Framework for Implementation Research (CFIR) is a well-established conceptual framework designed to facilitate a comprehensive assessment of multilevel implementation contexts, aiming to identify critical factors that could impact intervention implementation and overall effectiveness22. In our study, we employed CFIR as both a theoretical and practical guide to systematically examine various aspects related to the implementation and adoption of telehealth in China. CFIR encompasses five essential domains, namely Outer Setting, Inner Setting, Intervention Characteristics, Characteristics of Individuals, and Process. By leveraging this framework, we meticulously analyzed potential barriers, successful experiences, and recommendations associated with the implementation and adoption of telehealth in China. This approach allowed us to gain valuable insights into the complexities of implementing telehealth services and to develop a robust understanding of the factors influencing its success in the region.

Results

The screening process is depicted in the PRISMA diagram in Fig. 1. Initially, our search query yielded 1,351 records. To develop and calibrate inclusion criteria, two reviewers (JY and LH) independently screened the titles and abstracts of a randomly selected subset of 100 papers. Subsequently, the reviewers conducted separate screenings, excluding 1,193 papers. The kappa score, measuring agreement between the reviewers, was 0.75. After this initial screening, 151 papers were eligible for full-text review. Finally, 32 papers were included for data extraction. Additional details about the selected papers can be found in Supplemental Table 2.

Fig. 1
figure 1

The preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow diagram showing the study selection process regarding the implementation and adoption of telehealth in China.

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Overall statistics

Of the 32 papers included, most studies (n = 28) were published and reported on telehealth services during the early stage of the pandemic (January 2020 to April 2020). The most common service supported by telehealth systems was remote consultation (n = 14). Table 2 presents a comprehensive overview of the findings from the included studies. Notably, the majority of the studies (n = 21) did not assess or report any clinical outcomes following the implementation of telehealth systems. The most frequently reported outcomes were utilization (n = 27), satisfaction (n = 11), and effectiveness (n = 8) of the telehealth system after implementation. Figure 2 illustrates the distributions among diseases, infrastructure, and technologies/platforms of telehealth systems in China. Most telehealth systems provided services for general health (n = 11) and COVID-19 (n = 7). Internet and smartphones were identified as the most necessary infrastructure for supporting telehealth services (n = 24), with WeChat being the most commonly reported technology in the selected papers (n = 18).

Table 2 Summary of included telehealth articles (n = 32).
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Fig. 2: Sankey diagram with diseases, infrastructure, and technologies/platforms of telehealth system in China.
figure 2

HIS hospital information system, SMS Short Message Service.

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We mapped the major barriers and successful experiences identified from the papers to the domains on the CFIR (Table 3).

Table 3 Identified barriers, successful experiences, and recommendations for implementation and adoption of telehealth during the COVID-19 pandemic based on CFIR framework.
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Outer setting

Limited medical resources in rural areas pose a significant challenge in China, exacerbating health inequity in settings with scarce resources. As of 2020, the scarcity of licensed physicians nationwide led to a mere 1.56 village clinicians and assistants per 1000 rural residents on duty23. Furthermore, access to quality rural healthcare services is predicted to worsen due to the retirement of current practitioners and the allure of better opportunities for new healthcare workers in urban areas24. Due to the unequal distribution of medical resources15, patients often have to travel to different places to receive high-quality care25. With telehealth systems, patients can obtain such care at home, eliminating the burden and costs associated with traveling26. Moreover, these telehealth systems empower high-level hospitals, like tertiary hospitals, with abundant medical resources, to share their expertize and support primary and secondary hospitals that may be overwhelmed with patient load. Despite the benefits, rural areas have lagged in the implementation and adoption of telehealth systems27. During the pandemic, efforts were made to bridge this gap by enabling urban and tertiary hospitals to extend their medical expertize and human resources to rural and resource-limited areas28,29. Patients could remotely consult specialists at the core hospitals or order medications through online pharmacy systems29.

As promising as telehealth systems are, during the pandemic, the lack of standardized guidelines and protocols posed challenges in their seamless integration into clinical settings30,31. Immediate responses were required, and the necessary guidelines were yet to be developed. In response, customized policies, such as insurance coverage for telehealth visits, played a crucial role in facilitating the introduction of telehealth systems while alleviating the additional workload burden on healthcare workers and the financial strain on patients32.

Inner setting

Telehealth implementation in healthcare organizations may face challenges in evaluating its long-term impact on patients’ clinical outcomes sustainably33,34. Hospitals encounter difficulties in determining how to integrate telehealth systems into their existing clinical practices effectively. Moreover, implementing such systems requires additional human resources for development, maintenance, and operation, which can be particularly burdensome for healthcare organizations that are already facing staff shortages during the pandemic31.

To facilitate the successful implementation and adoption of telehealth systems without adding extra burdens to health professionals, some hospitals in China have designed innovative workflows that seamlessly integrate telehealth services into their existing practices without disrupting clinical work. For example, the West China Hospital’s intensive care units (ICU) developed a system enabling less experienced bedside physicians to communicate with a multidisciplinary team of senior and experienced physicians through videoconferencing before the COVID-19 pandemic28. This platform was adapted during the pandemic to provide telehealth services while maintaining the existing workflow and avoiding the need for significant additional investment.

To ensure the success of telehealth initiatives, we recommend conducting both short-term and long-term evaluations of the implemented systems. These evaluations can help increase buy-in and support from key stakeholders within the organizations. Additionally, gathering feedback and perceptions from relevant stakeholders can further enhance the effectiveness of telehealth systems. Some hospitals have reported positive outcomes with the introduction of telehealth, such as reducing the use of medical supplies and human resources. For instance, Zhang et al. found that implementing a vital sign telemetry system eliminated the need for nurses to check individual patients’ vital signs in-person, leading to a significant reduction in the consumption of personal protective equipment35.

Intervention characteristics

The technical features of the telehealth systems themselves may also hinder successful implementation and adoption. One concern is the stability and quality of telehealth services, especially synchronous patient-provider videoconferencing, where disruptions can occur, affecting remote consultations36. In order to accommodate and expand the coverage of telehealth systems, alternatives such as Short Message Services (SMS) could be utilized, which were easy to use, and affordable among populations with lower economic status, and could be applicable to a broader user group30.

Certain medical specialties, such as dermatology, heavily rely on images or video-based telehealth systems to ensure accurate diagnoses. However, the effectiveness of such systems depends on patients having access to devices with high-resolution cameras and a stable internet connection37. When telehealth encounters fail to provide adequate information, patients may receive inaccurate diagnoses due to insufficient data available to the providers for clinical decision-making38.

Privacy and security concerns also come into play during telehealth sessions, with instances of “Zoombombing” being a notable example. Such incidents can expose sensitive protected health information (PHIs) to unauthorized and malicious parties when commercial third-party software is used for telehealth services39. To safeguard patient information, it is imperative to have a dedicated Information Technology (IT) team that assesses the security features of the telehealth system, implements end-to-end encryption, and mandates the use of passwords and meeting locks for enhanced protection39.

On the positive side, telehealth systems supporting advanced services, like real-time clinical treatments, have been associated with minimal or no adverse events40. These platforms have the capacity to collect and analyze patient data on a large scale, offering valuable insights for population health management41. Additionally, hospitals can identify trends, risk factors, and best practices to optimize clinical decision-making42. A versatile telehealth system is capable of supporting multiple functions43, (e.g., consultation, making appointments, follow-up, medication orders, etc.)44 and various modalities (e.g., text, audio, video, etc.), thereby providing comparable services to in-person visits45,46,47.

Characteristics of individuals

Besides technical challenges, human factors are also known to pose significant barriers to the widespread adoption of telehealth systems. Patients, particularly those with lower digital literacy or limited access to technologies, may exhibit lower acceptance of telehealth systems48. The process of training and educating patients to use these systems can place a burden on the telehealth IT team37. In such cases, family caregivers have emerged as crucial stakeholders, providing essential support to patients facing technology-related challenges. For instance, for older adults using a home quarantine monitoring system that requires a stable internet connection and wearable device configurations, family caregivers who are more tech-savvy can play a vital role in assisting them49,50. Certain patient groups have expressed a preference for face-to-face interactions as it allows them to better communicate their health concerns48. To address this, some hospitals have adopted a hybrid approach, combining remote telehealth care with in-person visits, aiming to accommodate patients’ individual needs based on their health concerns and reasons for seeking medical attention19.

Moreover, users with lower digital literacy may exhibit reduced motivation to utilize telehealth systems. A prime example is older adults, who have been reported as the smallest user group consulting dermatologists through mobile applications for remote diagnosis51. To promote the acceptance of telehealth among such users, hospitals may opt to adopt widely used technologies or platforms like WeChat, rather than developing new and complex technologies37. This approach could potentially bridge the digital literacy gap and encourage more users to embrace telehealth services.

Process

Macro-level factors in society may impact the successful implementation of telehealth systems, necessitating an appropriate dissemination approach to streamline the process. For instance, a lack of awareness among the public about available telehealth services, such as mental health hotlines, may result in underutilization52,53. To address the issue, mental health hotline centers have effectively encouraged current users to share their positive experiences with telehealth systems on social media platforms52,54.

The adoption of telehealth systems requires comprehensive training for healthcare professionals, which can increase their workload, particularly during a pandemic37. Ku et al. found that therapists expressed lower satisfaction rates with a rehabilitation app because they had to invest considerable time in assisting patients with app installation37. Furthermore, clinicians may lack adequate training in using telehealth systems. To resolve this, some hospitals have adopted the “train the trainer” model, where trained staff pass on their knowledge of telehealth to new users37. This strategy effectively reduced the cost of training clinicians and facilitated their onboarding experiences with telehealth.

The development of telehealth systems during a pandemic may be impeded by a lack of technical and human resources within hospitals to build large-scale, robust systems. To overcome this challenge, partnering with third-party technology companies has been found to greatly accelerate the process and provide more scalable solutions beyond what hospitals could achieve independently48,55. Tailoring the telehealth systems based on the available technology infrastructure and the needs of the targeted patient populations is crucial, rather than implementing all components, some of which might not be affordable or accessible29.

Strategic development of telehealth system

China has provided valuable insights into promoting and supporting the development of telehealth systems. Since 2018, the Chinese government has implemented policies to encourage the growth of “Internet + health” initiatives, which involved establishing a “national telehealth network”56 In late 2019, an important milestone was achieved when online healthcare services were integrated into the national health insurance reimbursement system, a significant step towards digitizing the entire patient journey56,57. Furthermore, China made considerable progress in 2019 by launching one of the world’s largest fifth-generation (5 G) networks, significantly enhancing real-time coordination and capabilities in digital and telehealth services58. 5 G in health was critical for the “remote consultation platform” of Fangcang shelter hospital, for example, which connected its physicians with senior experts far away in Beijing in real-time43.

For other developing countries to effectively implement and adopt telehealth systems, they should consider creating an enabling environment based on their unique characteristics, paving the way toward a national healthcare ecosystem. While the long-term goal for developing countries may be to build a comprehensive telehealth ecosystem, their immediate priorities for implementation can differ based on their current state. Countries like China, India, Brazil, and Lebanon have already successfully implemented telehealth systems that proved to be extensively useful during the COVID-19 pandemic59. However, many LMICs encountered challenges in integrating telehealth systems into their existing healthcare infrastructure. One of the main concerns in LMICs might be the high initial costs associated with technology, as well as the need for reliable internet connectivity and coordination between various sectors and stakeholders, such as health ministries, science and technology ministries, local governments, and different-level hospitals60. In LMICs, government approval is typically required for launching telehealth programs, necessitating clear regulations, legislation, and funding to facilitate system development and implementation, which could lead to delays in adopting telehealth, especially during the crisis like the COVID-19 pandemic61.

We summarized the various infrastructures and telehealth system in Table 4, which may provide practical telehealth guidelines for developing countries or LMICs that have different and heterogenous infrastructures. We also provided example studies in different developing countries to demonstrate how the framework may be applied to different contexts. The basic and fundamental level of infrastructure is having access to devices such as cellphones that do not need internet connectivity, which may therefore be more affordable and accessible to a wider user population. These phones can receive short messages containing patient health information or knowledge from healthcare organizations.

Table 4 Infrastructures and mechanisms for telehealth systems and services.
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Moving beyond the basic level, the availability of internet connection, computers, and smartphones enables telehealth services like text-based remote consultations, through which patients can send symptoms and questions to providers and receive treatment recommendations.

Building upon this foundation, a more advanced infrastructure involves the integration of audios, cameras, and a stable internet connection. These technologies facilitate more versatile telehealth services with flexible modalities. For instance, specialties such as dermatology often necessitate photos and videos from patients to make accurate diagnoses, and text-based communication alone may not be sufficient. The inclusion of stable internet connections and video capabilities allows for remote, synchronous video conferencing, enabling interactive patient-provider communication and allowing clinicians to gather more comprehensive information.

The highest level of infrastructure encompasses wearables and cloud-based data storage, along with health information exchange capabilities. These components enable telehealth services that go beyond remote consultations. For instance, patients can use wearables to continuously collect health data such as vital signs. The patient-generated health data (PGHD) can be synchronized in real-time with providers, supporting clinical decision-making processes62. Furthermore, healthcare providers can also perform real-time remote treatments, such as surgeries and deep brain stimulation, through remote control40.

Discussion

Telehealth played a vital role in supporting the continuity of care during the COVID-19 pandemic. It was especially crucial for developing countries or LIMICs where healthcare resources were limited and unequally distributed. While previous reports on experiences to implement and adopt telehealth during the pandemic offered valuable insights, they mostly focused on describing the systems that were adopted in their specific contexts rather than a holistic review of the process of how they were implemented and adopted63,64. To address this gap, our review, guided by the CFIR, identified barriers, successful experiences, and recommended practices related to the implementation and adoption of telehealth from multiple perspectives. These perspectives encompassed macro-level practices, such as leveraging social media to raise awareness about telehealth services at the societal level. We also examined technological features that supported flexible modalities of telehealth services. Additionally, we explored processes that facilitated individual uptake of telehealth, such as involving family caregivers to assist children’s or older adults’ use of telehealth services65. Further, we proposed a framework comprising layers of infrastructures to support various levels of telehealth services. This framework may serve as a useful tool for developing countries or LMICs with different infrastructural readiness to plan their telehealth implementation strategies.

This systematic review reported the lessons and evidence of telehealth implementation and adoption in China during the pandemic from different aspects as guided by the CFIR framework. The findings from different aspects of telehealth implementation provide crucial implications at various levels.

In China, telehealth systems have proven to be instrumental in enabling patients to consult specialists beyond their physical reach. By using these systems for screening and triaging patients, hospitals have successfully reduced in-person visits, curbed in-hospital infections, and eased the burden on healthcare workers—crucial achievements during the pandemic. Furthermore, China’s experiences highlight that telehealth systems can also contribute to equalizing medical resource distribution and preventing in-hospital infections66.

A key factor in the successful implementation of telehealth in China was the presence of a compatible technological infrastructure. While internet connectivity and smartphones supported common telehealth services like diagnosis, more advanced real-time treatments necessitated sophisticated infrastructure66. While such infrastructure may have been easily accessible and well-established in developed countries, they were not yet pervasive and affordable in most LMICs or resource-limited settings. Developing and maintaining such infrastructures may also be time-consuming and costly for LMICs. Therefore, policymakers and practitioners should make use of existing infrastructures to support immediate telehealth services and start strategic plans for long-term infrastructure development. In addition, developing countries have heterogeneous infrastructure readiness and need tailored solutions to successfully implement telehealth. In China, commercial apps and software, such as WeChat, played a significant role as telehealth platforms. However, other LMICs might find apps like WhatsApp more suitable due to their popularity and familiarity67. These social networking platforms, including WeChat, Zoom, WhatsApp, Facebook, and FaceTime in LMICs provided a low-barrier communication tool already widely used in healthcare settings for video calls, phone calls, voice messages, and the sharing of images and videos. The infrastructure model we recommended (Table 4) may serve as a pragmatic framework for practitioners in developing countries or LMICs to plan telehealth implementation based on their infrastructure readiness and telehealth service goals.

The multi-component and personalized nature of telehealth, coupled with the rapid pace of change in mobile technology and the context-specific application of these tools, presents various challenges. Another important factor in successfully implementing telehealth services in LMICs is having a prepared and well-trained team that includes not only healthcare professionals but also health IT personnel. During public health crises, the immediate responses to implement telehealth services are crucial. However, hospitals alone often are not adequate for such efforts that require intensive technical expertize and resources. Some studies highlighted the importance of collaborating with third-party technology companies or government-funded information centers to facilitate the implementation and maintenance of telehealth systems43,55. However, it is important to note that burdening healthcare providers with the responsibility of managing telehealth tasks, including assisting patients in using the system, may lead to burnout. Thus, engaging and training health IT professionals is necessary to provide adequate support to the telehealth system. China’s experience suggests the potential of the cooperation of healthcare organizations, government, non-government agencies, as well as technology companies and financial inputs from philanthropic agencies.

In developing countries or LMICs, where patients’ digital literacy tends to be lower, there is increased vulnerability to privacy issues when using telehealth services. A large portion of telehealth services reported in the included papers used available commercial technologies such as WeChat and Zoom, but few reported strategies to address potential privacy concerns. As telehealth systems collected, stored, and transmitted protected health information (PHI), any security breach could pose harm to patients. While telehealth services were available in many areas of China, there was no stringent regulatory authority to monitor the quality of these services and maintain ethical standards. To fully harness the benefits of telehealth while mitigating negative consequences, it is essential for China and other developing countries to develop policies that ensure the safety of patients’ privacy, especially those with compromised digital literacy. Establishing robust regulatory frameworks and promoting data protection measures will be crucial steps toward the responsible and secure expansion of telehealth services in these regions.

Adopting telehealth into clinical practice in developing countries or LMICs may be a means to lower costs and conserve resources in the long run, thereby alleviating the burden of out-of-pocket spending and boosting the population’s access to affordable health care. Particularly given that out-of-pocket payments for health care services make for a considerable share of overall health spending in many LMICs that have no general health insurance available. Several studies conducted in LMICs have demonstrated the cost-saving potential of telehealth services, as healthcare providers can offer online consultations at a lower cost compared to face-to-face visits, while also reducing transportation expenses when health institutions are distant68,69. Healthcare systems should establish incentive mechanisms, such as performance appraisal, social prestige, and financial bonuses to facilitate the adoption of telehealth.

In many developing countries, the digital divide is a constant concern that impacts the effectiveness and coverage of telehealth. For example, older populations, especially those with low income, need the most medical resources but are the least likely to have access to internet-based social networking services. In addition, they may find it difficult to use complicated apps on mobile phones70,71. To address this issue, researchers have recommended leveraging off-the-shelf technologies that are already widely accepted by the public, such as WeChat37,72. Additionally, family caregivers play a crucial role in assisting patients facing technological challenges49. To reach a diverse and wide population to disseminate knowledge and health information, it is preferable to choose technologies that presume low barriers and high accessibility such as SMS or phone calls. It is important to increase the awareness of telehealth services among the public, especially marginalized populations who may benefit more from telehealth services but are not aware of them. This awareness-building effort is especially critical for LMICs, where rural populations might not have sufficient exposure to telehealth services.

To achieve more relevant and responsive healthcare services, it is essential to expand access to these services and implement organizational reforms to attain “close-to-client” approaches73. Decentralization has been promoted as a means for improving the responsiveness and effectiveness of health systems in LMICs74,75. Telehealth enables the expansion of care away from a centralized location to primary care, communities, and into the home, with primary care provider groups integrating virtual care directly into their practice76. Telehealth makes it feasible to distribute medical resources to remote and rural areas by decentralizing resources and services to primary care clinics77. In LMICs, developing infrastructures and policies may be time-consuming and may not yield immediate benefits, especially during the pandemic. China’s experiences suggested that governments could support core hospitals (e.g., tertiary hospitals) in developing telehealth systems and providing services to lower-level hospitals (e.g., primary hospitals or community health care centers). Patients in rural and remote areas with limited medical resources can consult medical experts from core hospitals through telehealth systems and receive high-quality care without traveling. In the future, China and other developing countries should further explore how to best allocate the limited healthcare resources through telehealth systems.

A developing country or LMIC can make strategic choices to guide the implementation and adoption of telehealth systems. These strategies are directly linked to or limited by the country’s governance and technology readiness. Countries that have government-led healthcare systems and robust technological foundations, such as China and Rwanda78, could prioritize strengthening the national telehealth strategy by prioritizing telehealth implementation at the national level. Building a national telehealth ecosystem requires multiple enablers, including the healthcare-governance model (centralized versus decentralized and predominantly public versus private) and digital readiness as a key element in defining a country’s implementation pathway for telehealth. In the near term, governments can intervene directly by creating dedicated teams responsible and accountable for the efforts around telehealth implementation strategy. The long-term strategy for these countries is to develop mechanisms for sustainable financing of the telehealth system.

Developing countries or LMICs that were with a private sector-led health technology effort and strong digital foundations could prioritize telehealth implementation at a national level through strategic partnerships with the private sectors. To attract private-sector investment and ensure the viability of telehealth initiatives, these countries could also consider enacting telehealth legislation and policies. For instance, India benefits from a flourishing digital- healthcare private sector and strong country-level action to develop a national telehealth ecosystem79. In the long term, LMICs’ governments should work with solution providers to evaluate how to integrate with national or regional telehealth systems and may depend on strong, top-level government leaders to champion system change and drive user adoption. Partnering with established organizations, service providers, or government agencies is often vital to reaching scale.

Developing countries or LMICs with nascent technology readiness may need to prioritize the development and improvement of digital technology readiness by investing in infrastructure and capability building80. In the short term, the solution providers and governments should build interlocking relationships when deploying telehealth platforms. With government incentives, solution providers may start developing critical use cases such as health care payments to bypass the challenging financing mechanisms and remote care, to prove the concept and lay the foundation for a telehealth platform. In the long term, these LIMCs can also build a forward-looking, national strategy that demonstrates the government’s commitment to promoting telehealth.

This systematic review has some limitations. First, because many studies were published during the pandemic, which aimed to rapidly share evidence and experiences, the quality of the publications was relatively low; the study design for these publications was primarily observational in nature with modest methodological rigor. Prior research has indicated that COVID-19 research ranked low in the hierarchy of scientific evidence, with numerous articles published in lower impact factor journals and within a shorter timeframe81. The present review did not aim to assess the effect of the reviewed systems or the quality of the target studies. We sought to identify the properties of telehealth systems and recognize the state of telehealth systems or services in China during the COVID-19 pandemic. Second, the majority of studies were conducted in urban areas and major modern cities in China, where the population has high digital literacy and overall economic development that may not be fully representative of the nation as well as developing countries. Although we included articles that were published in Chinese, we acknowledge that it can be challenging for projects in less-developed regions in China to publish research articles, which could explain why many study sites were from major modern cities. However, the resources and infrastructures from the selected studies varied and could offer insights into different resource-limited settings. Third, the included studies may not be fully representative since most of them reported on telehealth services in the early stages of the pandemic. This might be because China altered its prevention and control policy after April 2020, and quarantine restrictions were relaxed after the first wave. As a result, the momentum for building new telehealth systems might have gradually decreased thereafter. Nevertheless, we compared the results with other studies82,83 and found that our findings were consistent with those from other LMICs, indicating that our results were representative. Fourth, the implications from China may be applicable to countries that are similar to China in terms of their economies, rural-urban divisions, and healthcare systems. What worked effectively in China may not be directly applicable or feasible in other countries due to variations in resources, technology level, and healthcare delivery models. Socio-cultural factors also influence healthcare practices and patient behavior. Approaches that were successful in China might not align with the cultural norms, beliefs, and preferences in other countries. Adapting telehealth practices to account for these factors is crucial to ensure acceptance and uptake. Future work should explore telehealth service delivery in rural areas in developing countries or LMICs to find best practices and practical solutions.

Through a systematic review of telehealth systems used in China during the COVID-19 pandemic, we summarized the characteristics of the infrastructures and identified the barriers and successful experiences in implementing the systems. Successful implementation strategies of telehealth systems necessitate collaborative efforts from various stakeholders, strong governmental support, tailored designs for marginalized populations, and strategic technological infrastructure development. The experiences and practices observed in China hold valuable insights and can serve as robust evidence for broader scaling in other developing countries and resource-limited settings.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.