Telehealth at Scale
Opportunities in Rwanda’s Telehealth Market
Discussion with Rose Tuyeni Peter and Anja Smith of Percept.co.za, about Africa’s telehealth trends and how the UK firm, Babylon, are adapting their products to scale in Rwanda’s markets
- UK-based Babylon is adapting their product offering to African markets
- Restrictive regulations around telehealth have been relaxed
- Rwanda is the first African market where telehealth has been rolled out at scale.
Percept is a South Africa based, multi-disciplinary consulting firm that was started by Shivani Ranchod and Dave Strugnell, both of whom are actuaries. We have quite a wide skill set including actuarial analysis, data science, economics, public health and health financing. Much of our donor-funded work is in the public health sector and that is where our telehealth and innovation work is situated. We identified examples and initiatives that can have wider population-level benefits not only limited to a small private sector population, as typically found in Sub-Saharan Africa
Our telehealth or telemedicine work is much more South Africa focused, while the innovation work speaks more broadly to the primary health care innovations that are happening on the rest of the continent, especially in East Africa where there seems to be a lot of very interesting projects happening at this time.
Telemedicine Trends in South Africa
Our telemedicine work was borne out of a need to document recent changes in the telemedicine and digital health landscape due to Covid-19.
Prior to the Covid-19 pandemic, South Africa’s regulations were very onerous around telehealth and did not allow for first-time consultations to happen between healthcare professionals and patients through telemedicine. These regulations have now been relaxed due to the need to protect healthcare workers and keep patients out of health facilities, where Covid infections can occur, if possible. Now first-time consultations between health workers and patients can occur via telemedicine.
The relaxation of these restrictions has led to a lot of innovation and to the entry and expansion of new and existing players and their offerings in the market.
We have developed a series of three papers documenting these changes, two of which are available on our website and one is forthcoming. The insights we provide are based on interviews with the private sector players and they track the big growths we have seen in the telemedicine market, especially in direct doctor to patient telemedicine and other areas as well.
The insights we provide…track the big growths we have seen in the telemedicine market
The first report in the series, The nurse can see you now, provides an overview of the barriers and opportunities in the South African telemedicine market.
The Impact of Covid
Pre-Covid-19, there was a moderately hostile environment towards some types of telehealth, specifically, because of the regulations. During these times there were some very successful telemedicine models, particularly in what we have been calling the provider-to-provider models, where you have a health professional providing telehealth services to another health professional. Such as a nurse dialling in a doctor to get specialist assistance, and messaging apps for health workers such as Vula which facilitated patient referrals.
There has been growth in the uptake of direct-to-patient telemedicine models due to the use case created by Covid, which has increased demand for these services, and the relaxation of regulation, which has led to an increase in the supply of telemedicine services. While available data has shown that as Covid-19 lockdowns eased, direct-to-patient consultations have actually declined as patients return to using in-person consultations, but they had not declined to pre-covid levels and are still higher than before. However, this is a trend that will have to be monitored over a long period of time. When the technology has existed for longer and people become more used to it, and the funding models become more conducive, then maybe we will see uptake increase over time.
There has been growth in the uptake of direct-to-patient telemedicine models due to the use case created by Covid
Please refer to the Case Notes from the Frontier report for more detailed case studies on six telemedicine providers in South Africa.
Innovations in Africa
Our Africa innovation mapping series of reports aims to showcase some interesting technology-enabled tools in the primary healthcare setting that can help make primary health care more affordable, more accessible, and more equitable. We researched different solutions that have proven themselves in different regions and we spoke to different organizations in predominantly low- and middle-income countries like Rwanda, Ghana, Kenya, and Mozambique.
The series of innovation briefs we produce first attempts to create a framework for categorizing these innovations and secondly aims to describe some of these innovations in more detail. For instance, with Babyl, we explore the use of telehealth and telemedicine in the Rwandan healthcare system and the solutions that have specifically been adopted by their national health insurer.
We examine apps used by the community health care workers in the primary health care context, and actual examples in lower-income settings, like Mozambique and Kenya. We also considered how patient wearables and patient support can help to decongest healthcare facilities.
The briefs also look at the environmental factors that enable or impede innovation, looking at specific lessons from the different case studies, but also thinking about it a bit more broadly.
The Babyl Case study
Babyl is an ongoing telemedicine initiative in Rwanda run by the UK-based company, Babylon. In the UK, Babylon provides telemedicine services to the NHS. Under this project, Babylon is adapting their product offering to African markets. And Rwanda is the first African market where it has been rolled out at scale.
Babyl is a well and clearly defined product offering. The Rwandan government is also the first African government to start offering telemedicine to its population on a large scale through the Babyl.
The Rwandan government is also the first African government to start offering telemedicine to its population on a large scale through the Babyl.
Barriers to Adoption
While the innovations we considered mostly originated from the private sector, the reality in Africa is that scaling these innovations is heavily dependent on public sector adoption. Therefore, an inability to actually integrate the technology and data systems in a public sector context will leave the adoption of these solutions to only a very small market in most African countries.
Noteworthy is that relative to many other countries in Africa, South Africa has a comparatively large private sector with about 17% of its population having private insurance coverage, and about a third utilizing private health services on an outpatient basis. Therefore, South Africa’s, with their relatively large private health sector, may have a greater ability to pay for private-sector health services than those in some other African countries, which makes the market potential in other African countries comparatively more limited.
South African telemedicine regulations have been temporarily relaxed, but there is uncertainty as to whether they could go back to the way they were before. However, the general perception seems to be that this is unlikely to happen. While Percept has not spoken to regulators and therefore cannot report with certainty on the future of telemedicine regulations, it has been observed that in the public sector telemedicine is now becoming a part of the permanent solution of delivering primary health care services. This may indicate that it is likely that the regulation will at least become more relaxed. One of the recommendations of the No More Waiting Room series of reports is that the regulation itself needs an entire overhaul because there are aspects of it that are not in line with how people engage with online services, such as requiring written consent from telemedicine clients and physical copies of these consent forms. There is an adaptation that is needed in the regulation itself.
The difficulty is that there is often significant enthusiasm about telemedicine because the technology is impressive, and it sounds wonderful that you can now access services remotely. But the reality is that without wide-scale user adoption, and people actually feeling comfortable with the technology, and discussing the same depth of medical problems remotely, these initiatives will struggle to gain traction.
But the reality is that without wide-scale user adoption…these initiatives will struggle to gain traction.
There is also the difficulty of assessing impacts because the health outcomes that are actively measured often take a long time to change. In the brief on Babyl, it is mentioned that Babyl has commissioned a proper study on cost-effectiveness which is still ongoing. But there are some questions about sustainability from a financial perspective, at least in the short term, because it requires so much investment to get people to use it on a sufficiently large scale for the business case to make sense. This is something to keep in mind with all telehealth-specific offerings – without users feeling comfortable with the technology and seeing the value proposition in the technology, it is very difficult to generate large profits over the longer term.
Telemedicine or the innovations around it are not standalone offerings. They are not going to replace a doctor or nurse or anything like that. They will improve efficiencies and potentially bring down costs, but they need to be integrated with the way that doctors and nurses already do provide health care. And they need to be sufficiently close to their existing workflow so that you are not creating more work for people and not making it more onerous for patients to access care. So, while some might want to think of it as a total replacement of certain health services, it is really not, telemedicine is an additional way of providing health care.
Although initial investment might be an extra cost, the idea is that down the line you should be able to save costs by being able to triage patients more efficiently so that many patients do not actually need to go into health facilities, they will be able to receive care at home if they need to, or patients will be able to be sent to facilities that are most appropriate, as opposed to crowding hospitals when they actually need a lower level of care, for instance.
Telehealth big picture
I think there are benefits of potentially reaching patients who would not otherwise attend facilities. When taken into context, there are many African countries where we have high levels of communicable diseases like TB, HIV, and now COVID, that have consequences beyond the individuals, and these diseases can spread. However, you want people to rather engage with the system. And given the hours, many public facilities are open, for example between 8 a.m. and 4 p.m. or 7:30 a.m. and 3:30 p.m., as is the case at least in some settings in South Africa, it is very difficult for people who are employed to actually attend a health care facility. And if care can be made more convenient to people who would otherwise not easily be able to access health care, then we may reach populations we never reached and be able to achieve better control of the health conditions and burdens that health systems face.
While we cannot speak to the profitability of the sector, we have observed an increase in players entering the South African market. Some of them are already existing practice management software companies that are now adding telemedicine services on top of their existing product offering. These companies already have some level of profitability in other areas and this is kind of a start-up offering for them.
Also, some medical aid schemes in South Africa are also branching out into providing telemedicine services as part of their product offering and as a way of capturing their own patient market and doctor networks and accessing more patient data. I think this is something to be aware of for players that are entering the market – there are some big dominant players that have a competitive advantage in accessing telemedicine users, both clinicians and patients. So, though new, it appears to be becoming an increasingly competitive market.
Regulations in South Africa are an issue. Also, certain dominant players in the market operate in ways that make it challenging for new market entrants, and could pose a barrier to entry and competition.
There is also the issue of infrastructural deficit in Africa that makes it very difficult to provide digital health services because data and the internet are expensive, and they are not widely accessible to everyone.
Even electricity is a factor. Across some of the big cities in Africa, you see little kiosks where people charge their cell phones just because electricity is not always available in their homes, this could be an even bigger challenge in rural areas. So, infrastructure is a big constraint.
This piece is based on our conversations with Rose Tuyeni Peter and Anja Smith, Health & Development Economists, respectively, @ Percept, South Africa. It was edited and summarized for brevity and clarity by Anthony Atigari, Executive Director of Canada Africa Business Forum