ClickHealth - a rural telemedicine service

Rural communities from hard-to-reach areas, in particular the women and adolescent girls, lack access to primary health care consultation services from qualified doctors: The majority of individuals, in particular the women and adolescent girls living in hard-to-reach remote rural communities do not always have access to primary health care. The uneven ratio between the limited number of doctors and the high number of people seeking primary healthcare is one of the primary reasons behind this. As per the World Bank’s collection of development indicators,  Bangladesh has 6.37 doctors per 10,000 people. The situation is even dire in rural areas, especially in the waterlogged and riverine areas of Bangladesh. The government health facilities accessible by rural population are typically situated at upazila headquarters, which are far away from rural households. So the people often need to travel miles to visit health facilities, sometimes even need to spend the whole day and could not but bear extra out-of-pocket expenses for primary healthcare services. Therefore, substantial gaps are evident in primary healthcare services for rural disadvantaged communities, especially the women and adolescent girls in Bangladesh.

Negligence and ignorance among rural women and adolescent girls for getting primary care on gynecological and SRHR before problems become evidently serious: In Bangladesh's rural areas, 69% of women do not have access to decent healthcare, let alone SRHR. In the vast majority of circumstances, discussing SRHR is frowned upon. Poor economic conditions, social and cultural stigma, attitudes and views, gender-based violence, illiteracy, and the lack of healthcare facilities all have an impact on women's health in rural Bangladesh. Women and teenagers, on the other hand, feel more comfortable sharing their difficulties with community health professionals, who often lack sophisticated understanding about health-related issues. Furthermore, owing to misinformation, primary care is not always treated appropriately, and most individuals want to ignore their health-related concerns. They are unaware that seemingly minor symptoms may signal a predisposition to incurable/serious illnesses. They have a tendency to handle such illnesses on their own by following their ancestors' advice, which is frequently incorrect and has a significant influence on their reproductive health. Furthermore, even if they agree to go to the doctor, female doctors are not always accessible to help patients with their difficulties. As a result, they are hesitant to disclose important health information with male doctors and only consult with them when absolutely necessary.

Overburdened secondary healthcare facilities with patients required primary healthcare support only: A number of health-related difficulties require primary healthcare consultancy and support only. But as people are often not aware of that, irrespective of the seriousness of the health events, they could not but rely on the doctors working at secondary healthcare facilities. Since the doctor-to-patient ratio is already low, the outdoor patient care units at secondary health care facilities of rural Bangladesh are often inundated by patients seeking primary healthcare and therefore, overcrowded.

Unnecessary consumption of antibiotics among rural communities following the suggestions from rural quacks and pharmacy owners: When it comes to health difficulties, most of the rural residents turn to local pharmacists or inept quacks. They frequently give detrimental antibiotics for the patients' speedy recovery due to their lack of knowledge and experience. Patients are not aware of or taught about the hazardous side effects of antibiotics, thus they do not hesitate to use them. As a result, their health suffers in the long run, and antibiotic resistance develops.

Existing telemedicine services are struggling to cater to the needs of the rural people, who typically do not have the literacy level and logistics required to access telemedicine services: A significant number of telemedicine services are currently accessible. However, the efficacy of such services is still debatable. Because rural individuals typically find it difficult to utilize cellphones to obtain telemedicine services, the majority of telemedicine services are geared toward urban centered rich people. Furthermore, the disclosure of telemedicine services might be costly for rural residents.

ClickHealth is an android and web-based application that is used to give healthcare services to rural populations, particularly to women and adolescents, who have a variety of gynecological disorders or have questions about their Sexual and Reproductive Health and Rights. Patients may access a pool of doctors through this portal, which is run by local female mediators (for example; local entrepreneurs).

Because of infrastructure issues, the majority of doctors prefer to practice in metropolitan regions. This creates a significant void in the healthcare service industry. Furthermore, a considerable percentage of female physicians who have just begun their careers may be compelled to take time off owing to pregnancy or other concerns. We're looking for female doctors with a charitable attitude toward society who would be ready to give low-cost treatments to remote regions. 

Local mediators are given instruction on how to communicate with patients and physicians. They engage with patients, construct a patient profile in the Android application, upload medical documents, and gather important health information (blood pressure, height/weight, blood sugar, temperature, pulse, and so on) from patients to schedule doctor's appointments based on their needs. When doctors accept the appointment, they get access to the patients' medical records. Doctors and patients can converse online with the aid of intermediaries (audio call, video call). Doctors can prescribe vital pharmaceuticals to patients, and individuals can receive those prescriptions with the help of intermediaries.    

Through the help of our android and web based platform, females can freely talk about their reproductive health and show their concern. Since most of them lack proper education to operate the platform, we’ve selected groups of intermediaries and trained them about the application so that they can help the women in need of doctor’s consultation. So far, more than 22,000 consultations have been conducted through ClickHealth.

The impact of ClickHealth can be categorized into three timeframes. If we focus on the short term impacts, we can emphasize on the following points:

• Our solution ensures the savings of costs for the involved stakeholders. Since patients do not have to travel long distances just to consult with doctors, they can lessen their expenditure and time.  It is estimated that it can save approximately 90 million BDT in costs for the beneficiaries. Besides, it can be a great source of income for the intermediaries and local youths as well. 

• Since the patients can reach skilled doctors throughout the country with the help of this application, the chances of maltreatment will reduce and the chances of serious diseases getting timely treatment will increase. Besides, female patients can directly communicate with the doctors and can talk about their health problems without any hesitation. This will boost the confidence and comfort within women to seek primary healthcare services on time

As for the medium term impact the following impacts can be identified:

• Since the patient volume is very large in our country, ClickHealth helps to reduce the burden on the government healthcare facilities. As a result, doctors can provide their services without any additional pressure.

• Some symptoms may mislead patients sometimes. There are chances that a patient may get over anxious by having serious/mild symptoms. In many cases, after carefully reviewing, it can be found out that the disease is not serious and the patient may recover after getting primary treatment. ClickHealth plays a monumental role in determining such cases. 

• Sometimes, women and adolescents refuse or delay getting advice on gynecological and sexual health related issues, due to lack of female doctors, and the cases become extreme due to negligence. ClickHealth allows these cases to be intervened on time and at an affordable price. 

The long term impact may include the following points:

• Over-prescription of antibiotics can cause antibiotic resistance. Since our solution will enable us to reduce the chances of maltreatment, such risks of antibiotic resistance will reduce. In the long run this will diminish the chances of antibiotic resistance among the larger population.

• Our solution will decrease the pressure on secondary health care facilities on a rural level. This will result in a decrease of expenses in healthcare. 

Mridul Chowdhury – Team Leader - Mridul Chowdhury has more than 20 years of extensive experience in development consulting and Information Communication Technology for Development projects in Bangladesh and 14 other developing countries including Nepal, India, Myanmar, Philippines, Senegal, Gambia, Niger, Zambia, Botswana, Rwanda, Egypt, Haiti, and Guatemala, spanning 3 continents with particular focus on developing mobile applications in order to stimulate a range of government and non-government initiatives across development sectors including Health, Family Planning and Nutrition, WASH, Agriculture, Livestock and Fisheries, Education, Livelihood and Poverty Reduction, Youth and Economic Empowerment, Climate Change, Disaster Risk Reduction, Humanitarian Responses and Governance. He founded and currently works as the Chief Executive Officer (CEO) of mPower Social Enterprises Limited (formerly ClickDiagnostics Inc.). Being the CEO of mPower, he led the design, development and implementation of 200+ IT solutions while ensuring complicated multi-sectoral, multi-level and multi-stakeholder engagement. Some of these solutions are being implemented nationwide and intended to reach 100+ million beneficiaries globally. He also led multiple donor funded projects for the capacity development of the frontline service providers and their managers engaged in public health services. In 2013, under his leadership mPower he started providing Road Accident Prevention and Post Accident Response Management Services that is known as TraumaLink services of mPower which gained immediate attention and praise from relevant stakeholders in Bangladesh and abroad. In addition to mPower, he also co-founded D.Net, one of the largest ICT4D NGOs in Bangladesh, Jeeon Bangladesh Limited, and Get to Data (D2). Earlier he also worked with UNDP, Bangladesh Enterprise Institute, Ministry of Planning of the Government of Bangladesh and Center for International Development at Harvard University, USA in different capacities. He graduated summa cum laude with triple majors in Economics, Mathematics and Political Science from the University of Texas at Austin and MPA in International Development and Development Economics from Kenney School of Government, Harvard University, as Dean’s Fellow. He also attended executive education in Social Entrepreneurship at INSEAD Business School, France and Stanford University, USA.

Dr. Md. Abdul Baqi – Primary Healthcare Expert - Dr. Md. Abdul Baqi has over 30 (thirty) years of experience of working with the Ministry of Health and Family Welfare (and past equivalents) in Bangladesh. In a complete career with the MoHFW Bangladesh, he had previously served as the Divisional Director of Health, Dhaka division and the Director, Primary Health Care (PHC) & Line Director, Essential Service Package (ESP-Health) with the DGHS. After retiring from Government Services, he worked with multiple local and International NGOs such as BRAC, Sajida Foundation, Jeeon etc. in different capacities. To be exact, for BRAC he supervised the activities of Balkh Provincial Hospital and District Hospitals of Bulkh Province, Supervision of BRAC Shu Shasthaya Program. For the Sajida Foundation he introduced a paramedic training program. Prepared a curriculum, syllabus and training materials for the students. Introduced teaching through Multimedia. Carried out liaison and advocacy with the GoB on behalf of SAJIDA foundation. Before joining mPower, he worked as the Medical Advisor and Capacity Development Specialist at Jeeon, an NGO connecting rural to and quality healthcare by providing local intermediaries with the training and equipment to facilitate meaningful consultations with remote doctors. Since 2015, Mr. Baqi has been working for and with mPower as the Director of mHealth and contributing as the subject matter expert in all digital health projects being carried out by the company. He has also been serving as the Chief Training and Capacity Development Officer for mPower’s TraumaLink services that addresses the lack of a dedicated prehospital emergency medical system in Bangladesh with a volunteer-based network of first responders for traffic injury victims over the years since 2013.  Dr. Baqi has completed his MBBS from the Rajshahi Medical College and also holds a Certificate on Medical Education from the Chulalongkorn University, Thailand, a Post-graduate diploma in Tropical Medicine and Hygiene (DTM&H) and Certificate in Teachers Training for Primary Health Care at the University of Liverpool. In addition to Bangladesh, he has study and work experience in the United Kingdom, Sri Lanka, Thailand, Nepal, Switzerland, Myanmar, India, Egypt and Kenya.

Tajkia Rumman Worthy – Service Manager – Tajkia Rumman Worthy has more than 7 years of experience in working in Public Health as a researcher. After completing her MBBS from Shaheed Ziaur Rahman Medical College, Bogura, Bangladesh, she started her career as a Medical Officer at Lab One Hospital and Diagnostic Center, Dhaka, Bangladesh. Later she completed MPH in Epidemiology from Bangabandhu Sheikh Mujib Medical University and started her career as a researcher. She worked as a Research Intern for icddr,b and later joined as a Research officer for the Department of Public Health and Informatics (DPHI) of Bangabandhu Sheikh Mujib Medical University in 2018. In January 2020 she joined mPower as the Research Manager and is currently learning the research projects awarded to the company. She has multiple research publications published in different local and international journals.

Apart from that, mPower has been in the telemedicine business utilizing ICT platform since 2013. At that time, mPower incubated and deployed a telemedicine model with rural pharmacists that have received multiple awards and grants for expansion. Later the model was established as a separate business entity called Jeeon, which is still in operation. Built on that experience, on the onset of COVID-19 in 2021, we have developed a proposed full-fledged telemedicine service with an advanced platform including analytics, and started with 25 women service entrepreneurs or service centers in two districts of Bangladesh that are managed by United Purpose, an international NGO. Initially we had a panel of doctors capable of providing 200 consultations per day. Soon after we started providing our services, it was widely accepted by the communities we are serving. Following that we have conducted an assessment among the population served, from where we received testimonials on how our solution enabled them getting the primary healthcare services, which they might not get otherwise. Our initial success gives us the confidence that our proposed solution and technology works in the given context. Therefore, we keep increasing our service centers and panel of doctors. Currently we have 58 service centers in 4 districts in Bangladesh in partnership with United Purpose.

As we are primarily looking for expanding/scaling up our service network in different locations, we are primarily looking for financial support that requires us to mobilize and train up local service entrepreneurs or intermediaries in those areas. We would also like to utilize a part of financial support to conduct promotional campaigns among the rural communities, where a part of the consultancy fee required to be paid by rural communities will be subsidized at the very beginning to demonstrate the usefulness and ensure wider acceptability. Apart from financial support, we also seek mentorship, coaching and strategic advisory support from SOLVE. Given that our solution is selected, it will give us further exposure in the media and conferences and thus, help us build trust among the stakeholders including policy makers. More importantly, we are seeking access to global standards of telemedicine from SOLVE.

Due to the larger gaps in the healthcare services, especially in rural areas, it has somehow become inevitable to implement tele-consultation and the Bangladesh government is also encouraging such initiatives.  However, what we have observed in the typical tele-consultation services is that they have sometimes proven to be less effective. Since these models mostly involve direct communication between doctors and patients, there remain some problems. Since most of the rural patients lack education, they do not know how to provide vital information to doctors (they do not know how to measure diabetes, blood pressure, pulse). As a result, doctors cannot provide proper services without knowing the patient's condition. Besides, most of the time the patients do not know and are unable to communicate what medications they are currently on. There are also problems in language too since their accent may not seem understandable to the doctors.  Therefore, our solution “ClickHealth” focuses on an innovative approach that is assisted tele-consultation, where the local semi-educated female entrepreneurs are serving as the intermediaries. They use mobile applications to capture images of current medicines along with vital health information and get appointments from doctors when necessary.  They interpret what the patient wants to describe to doctors when they are on video/audio call. Thus, our solution has overcome the barrier to bring rural population under telemedicine services for primary healthcare with its innovative intermediary based model. 

Also, we are solving a critical demand-side problem, which is access to primary healthcare advice for women and adolescents, a demographic that is particularly deprived of the right healthcare advice at the right time, leading to many kinds of gynecological and sexual health-related complications, that get more and more complex over time, when left untreated. This problem is particularly acute in water-logged areas of Bangladesh cut off from the mainland, where healthcare facilities are mostly based out of.

 We are solving the problem through a social business model by utilizing untapped resources from the supply side, and creating income opportunities for skilled but unemployed female local intermediaries based in communities, and also for female general physicians, who want to provide tele-consultation service from the comfort of their own homes for added income source.

 ClickHealth is like an Uber for healthcare connecting disadvantaged women and adolescents in rural communities to experienced female doctors in urban areas, at an affordable price, with the gender-sensitivity needed for women and adolescent issues.

Currently we are serving 500+ patients each day from 58 service centers in 4 districts, operated by local women entrepreneurs. We would like to increase the number of service centers or local intermediaries to 200+ within the following 12 months and eventually we want to ensure at least one service center at each upazila in Bangladesh within the next 5 years and build the capacity to serve 2000+ patients on each day. Thus, we want to bring 10 millions of rural people from all over Bangladesh under our service coverage.

The list of indicators for measuring the progress towards impact goals are described in the following:

• Average out-of-pocket expenditures of rural households for accessing primary health care: We want to lower individual health-care costs with our service. We collect data from our patients and analyze it for a better understanding of whether or not their expenses have decreased.  

• Number of women and adolescent girls received consultancy on Gynecological and SRHR issues from our service points: We calculate the number of patients handled by each intermediary in a certain location over a period of time and compare it to historical statistics. This allows us to see how far we've progressed and how many places we still need to cover to attain our objective.

• Wait time for care at secondary care facilities: Reduced load at the secondary care level is one of ClickHealth's goals. However, we calculate the wait time for care at secondary care institutions to determine the result. We want to know if individuals have to wait for longer hours for secondary care services or if they have to wait for less time. This provides us with insight on the impact of our services.

• Monthly income of the intermediaries: Because our solution will provide job opportunities for a large number of rural intermediaries, we examine each intermediary's monthly revenue and monitor the coverage of our services to determine if we have had an impact.

Our solution is harnessing a telemedicine platform that entails an android application for the rural service entrepreneurs or intermediaries and a web-based mobile responsive platform for the registered doctors and system administrators/service managers. The registered patients are connected to the system with a system generated Unique ID and mobile number. Following diagram shows the overall process flow our the corre technology we are utilizing.

Female Service Entrepreneurs/Intermediaries:

Female service entrepreneurs who work as an intermediary between the patient from rural areas and the remote doctors utilize the mobile application to manage patient profile, register new patient with a system generated unique patient ID, book appointment, deliver QR code-based patient ID card, update vitals and other information according to patient’s medical condition, facilitate video consultation with doctors according patient’s needs and provide printed doctor prescription to the patients. After updating all vital health information, once the intermediary submits a patient for booking an appointment, the name of that patient is added in the queue shown on doctors’ dashboard. From the queue, any doctor logged in the platform can accept an appointment request from his/her dashboard. After accepting an appointment request, the doctor can connect to the patient through the intermediary on video or voice call. After the consultation session, the female intermediary and the patient get the prescription of the doctor through an SMS. The intermediary can also download a doctor’s prescription from the mobile application and print where applicable. 

Remote Doctor

As for the remote doctors, they can pick new patients from a queue and initiate the process for video call. The doctors can view patients’ profiles, vital information about their health conditions, and clinical history. After checking the profile, clinical history and vital signs of a patient, the doctor meets the patient on a video or voice call through the intermediaries. Following the conversation, the doctor creates a prescription, which is added to the patient’s profile and can be downloaded by the pharmacist. The prescription can also be delivered to the patient and/or the intermediaries through an SMS.

Patients

The female service entrepreneurs or intermediaries will be able to provide the beneficiaries with a QR code-based ID card. Apart from that, the system can send system generated prescriptions and other information e.g. reminders for next visit through SMS directly to the patients in case the patient is registered using a mobile number.

System Admins/Service Managers

Systems admins or Service Managers are involved in operational reporting, management of users, roles and access control. 

The proposed solution is one of the different social business models incubated at mPower Social Enterprises Limited (www.mpower-social.com)

The top management of mPower Social Enterprises Limited is committed to managing a culture that values diversity and is equitable and inclusive. Therefore, they had made it a priority to treat all employees equitably, and to create the conditions to make everyone feel welcomed and included in the organization. To incorporate diversity, equity and inclusion in the workplace, the organization already has an established framework in place which ensures equal employment opportunities for deserving candidates irrespective of races, religions, genders, and regions. To be specific to the ClickHealth endeavor of the company, the solution primarily focuses on equitable access to primary healthcare services to the disadvantaged people, in particular rural women and adolescent girls from disadvantaged and remote hard-to-reach rural areas of Bangladesh, who otherwise would be excluded. To make the solution inclusive, we mobilize the intermediaries, in particular female service entrepreneurs from their respective communities. On the other hand, 1 out of 3 full-time staff engaged in ClickHealth operations and 90% of the doctors currently engaged with ClickHealth initiative are female.

KEY RESOURCES

• Licensed General Physicians: To run our activities, we primarily need licensed general physicians (GPs), in particular female GPs willing to work from home at their convenience
• System Administrators/Service Managers: We also need a few full-time staff to administer the existing telemedicine platform and also to manage the operations
• Telemedicine Platform: Although we already have an existing telemedicine platform in place, we need to maintain and update the solution time to time 

KEY STAKEHOLDERS

For smooth operation of our services, we need to build strong relationships and establish confidence in our services with a few key stakeholders in particular the local government bodies, local administrations and Directorate General of Health Services.

KEY ACTIVITIES

• Mobilization and Training of the Local Female Service Entrepreneurs
• Recruitment of doctors willing to working from home at their comfort
• Conduction of Promotional Campaign
• Maintenance and upgradation of the telemedicine platform 

TYPE OF INTERVENTION

Primary Healthcare Consultation

CHANNELS

• Telemedicine Platform (mobile application with corresponding web panel)
• Female Service Entrepreneurs/Intermediaries

SEGMENTS

• Beneficiary: Female service entrepreneurs/intermediaries and female doctors willing to working from home at their comforts
• Customer: Rural patients seeking primary healthcare service, in particular women and adolescent girls

VALUE PROPOSITION

• Beneficiary Value Proposition: Increased earning opportunities for rural intermediaries and increased earning opportunities by working from home for female doctors while serving the disadvantaged population 
• Impact Measures: Average out-of-pocket expenditures of rural households for accessing primary health care; Number of women and adolescent girls received consultancy on Gynecological and SRHR issues from our service points; Wait time for care at secondary care facilities; Monthly income of the intermediaries
• Customer Value Proposition: Primary Healthcare Consultation at affordable price which is far below the cost that they require to get similar service from nearest government health facilities

COST STRUCTURE

• Remuneration for Doctors
• Remuneration for Service Manager/System Administrator
• Online Telemedicine Platform Maintenance Cost

SURPLUS

Expansion in other geographical areas

REVENUE

Consultation fee

mPower offers this service as part of its social responsibility to provide a much-needed service that can pay for itself after initial small investment. The technology platform developed for the service is mPower's investment and is not counted as part of the cost that needs to be recovered. Our unit economics calculations suggest that if each tele-consultation service is priced at around USD 1.2 (BDT. 100) and there is a 50:50 revenue sharing arrangement between mPower and the local entrepreneur, then the operation is financially feasible for both parties. One General Physician (GP)  can conduct 40 tele-consultations (12 minutes per consultation session on average) in an 8 hour workday that generates a total USD 48 per day. The daily monetary compensation needed to be paid to a GP is about USD 18. From 40 consultations, mPower gets a daily revenue of half of USD 24 (USD 1.2 divided by 2, and then multiplied by 40), leaving a daily surplus per doctor of about USD 6 to cover other logistical costs. For each local entrepreneur, a daily average of 10 tele-consultations gives them an average income of about USD 6 (USD 1.2 divided by 2, and then multiplied by 10), which converts to a monthly income of USD 156, and yearly income of USD 1872, which is about triple the per capita income of the country. Through the project, we will only provide the initial support that the entrepreneurs need to promote the service in their locality, and have initial word of mouth viral marketing. After that, the service continues on an auto-pilot mode with little external support.

We have already received funding from several donor organizations such as GIZ, Dalio Foundation etc. We mostly need setup funds for setting up the services in locations - the operational model of sustaining the service through doctor consultations is covered through the social business model described above.