Implementation Challenges of Telemedicine in Rural Bangladesh: From My Experience

In this moment of crisis, when going to hospitals are potential spreaders and the inability to physically consult doctors has emerged as a crucial obstacle for patients seeking medical assistance. The need for "Telemedicine" is very essential now more than ever. I am really happy to see that organizations like Pathao, Shohoz, Prava Health, Pulse One, Digital Healthcare Solution, etc, and private hospitals like Square and United have also come with telemedicine/teleconsultation solutions to solve this problem.

From October 2015 to November 2018, I worked for Jeeon Bangladesh Limited. At that time, Jeeon had a telemedicine platform that bridges the divide between rural patients and quality healthcare by providing local intermediaries with the training and equipment to facilitate meaningful consultations with remote doctors. I was the Head of Operations of that Telemedicine Program till 2017. Jeeon had stopped the telemedicine program due to numerous implementation challenges that can't be solved by Jeeon itself. Moreover, the readiness of the market is also an important factor in that time too. In this article, I am going to share the challenges that we faced during the time of implementation.

To take the service of the Jeeon Telemedicine program (under the brand name of Projotno), a patient only had to come to the nearest drug-shop-cum-Projotno-centre in his/her nearest bazaar. Then the rural pharmacist of that center took his/her problem, history, and some primary vitals like weight, blood pressure, blood glucose, etc and send that information to a doctor by using Projotno Telemedicine App and requested an appointment with a relevant doctor. For example, if the patient come with a skin related problem, then within minutes, s/he was connected to a dermatologist sitting in Dhaka, who after reviewing his/her symptoms and pictures of his/her skin and talking to his/her, sent his/her a prescription over the internet. The prescription was printed out with the doctor's e-signature, and she could walk away with the required medicines within 30 minutes.

We deployed 42 franchisees of Doctor-in-a-Tab across 4 Upazilas (subdistricts) in Northern Bangladesh (Netrokona and Kishoreganj) over the course of two years of experimentation, and through them served nearly 10,000 telemedicine patients. We chose unions that have a minimum population threshold of 20,000; thus 36 centers had a catchment population of ~700,000+. The pharmacies were located in the well-established middle to large scale markets with at least 50 shops and >=5 pharmacies, ensuring they were frequented by patients from all neighboring villages, there were strong network and road connectivity, and relatively stable electricity.

The price of each conversation is nearly USD 4, which expectedly was beyond the reach of the poorest income quintile of the population, but it served other underserved segments like children, elderly and female patients (60%+). Our target clients were patients in rural Bangladesh that reside at least 20 KM / 1 hour away from a major urban or medical hub, thus without direct access to qualified doctors, and earning between USD 64-260 per month per household (not the extreme poor). All of our selected centers were in Bazaars that were 10-35 kilometers from the nearest urban hub. In the typical setting patients in these areas incurred large opportunity costs such as transportation cost, doctor’s fee, prescription costs, diagnostic costs, etc. traveling to towns (amounting to upwards of USD 25), hence we expected that they would prefer an alternative of visiting a “Dhaka Doctor” at their next-door pharmacy for <USD 10 per visit (including prescriptions). This assumption was partially validated since we have been able to serve ~10,000 patients in the course of the last 2.5 years.

We also initially assumed that because RMPs are invariably male, we would serve a mainly male clientele. However, to our surprise, we found that a majority of our patients were female. We attribute this unexpected finding to the fact that male patients have more freedom of movement and mobility and hence can visit the town for care by themselves, whereas female and other less mobile customers (children & adolescents – 24%, elderly – 20%) tend to rely on the pharmacy for all kinds of care in the absence of financial means and mobility to travel. Therefore, this intervention was reaching the most marginalized and underserved segments of the population except the extreme poor.

Challenges: Difficult and expensive to deliver results consistently with telemedicine

When we launched, we expected remote consultations with doctors to solve the key challenge of rural primary care – bridging the quality gap inaccurate diagnosis and treatment. In reality, we found that delivering a consistently accurate diagnosis and treatment was extremely challenging.

• First of all, doctors required more diagnostic tests than usual to diagnose problems accurately because of the inability to touch and examine the patient themselves. But due to the lack of diagnostic facilities nearby, patients would often not follow up with a diagnostic test. Moreover, if they have to go to the city to do the diagnostics test, then they can also take doctor consultation from there. So the lack of diagnostics facilities in rural areas was a huge challenge we faced.
• Secondly, even when a patient was diagnosed accurately, sometimes the medicines were not available at the pharmacy due to poor supply chains or inadequate prior demand. Our field staff went out of their way to deliver uncommon medicines to our centers, but it became unmanageable and costly to sustain that long term and at scale.
• Thirdly, many patients required treatment beyond just medicines, such as procedures and surgeries. We chose not to charge these patients for the referral advice we gave them, but because there were very few quality hospitals and clinics nearby, we could not endorse any particular referral facility which disappointed patients. Patients also did not like to be told to go to the town after coming to our pharmacies with the hope that the problem would be resolved locally.

So, ensuring only good doctor consultation is not the only verticle that needs to be solved. To launch successful telemedicine, other verticals like diagnostics tests, availability of medicine, and referral services should be formed.

There was also some demand-side barriers like due to a lack of health awareness and education, there is very little understanding of the concept of “quality” in healthcare. If a patient feels better from a stomach ache after taking a high-dose painkiller, they often would prefer that service over a doctor who diagnoses it as simple indigestion and asks the patient to sleep it off. Therefore, it was a huge behavior change for people to opt for an expensive doctor consultation when they could spend one-fifth of the amount on a few low-quality pills. Moreover, by the time a patient delayed care-seeking and self-medicated a few times with no results, the problem had often escalated beyond the ability of doctors to treat remotely, and referral was the only option, which was in turn highly unpopular with patients.

What we have attempted to adapt to the challenges?

Diagnostic sample delivery: In order to mitigate the challenge of diagnostics, we initiated a pilot in partnership with a diagnostic center in Kishoreganj called Health Aid. Under this pilot, patients would deposit their samples (blood, urine and stool) in the center and a representative from the diagnostic center would pick them up at a specific time of the week. When the samples were taken and reports were generated, the reports will be delivered back to the same pharmacies. This also would include a discount for patients.

What we found in practice was that in most prescriptions, blood/urine tests were accompanied by radiological investigations like Ultrasound or X-ray, which meant that the patient had to travel in person anyway.

Dermatology specialization: We had found from the first few months of the pilot that dermatology as a specialization was generating much better Positive Patient-Reported Outcome (PPRO) measures than general practice cases. This was due to the fact that dermatology is a largely visual illness, and can be diagnosed with a high degree of confidence from pictures alone without relying on a lot of diagnostic tests. We decided to hire more dermatology specialists and market the service as a dermatology specialty service. We were trying to see if we could get a higher patient flow per-center if we did that. We found that while we got a bigger share of dermatology patients after the marketing, the total patient volume did not increase by much, which indicated that we had already saturated the limited demand for telemedicine in the market.

Conclusion:

I am really happy to see that in the last couple of years now lots of organization is coming with a solution for remote consultation. Moreover, the whole process expedites due to the Covid-19 situation. However, most of the solution is focused mostly on urban or only doctor consultation part. However, if someone wants to build a robust remote doctor consultation, s/he also needs to focus on the other 3 important verticles - diagnostics test, medicine availability and also referral services.