Solar powered hybrid healthcare services

Rural and hard-to-reach communities in Fangak county, South Sudan have longer commute time, fewer care options, and receive little to no preventive care. They do not visit doctors regularly until at the later stages of illness. Consequently, they experience worse health outcomes. For instance, one in ten children die before the age of five. The rate of maternal deaths per 100,000 live births is around 1,150, and a routine immunization rate is less than 45 per cent. Health priorities in Fangak include the reduction of high maternal mortality and infectious diseases notably malaria, tuberculosis and HIV. Some of the bottlenecks for improving access to healthcare in Fangak have been the severe shortage of healthcare workers, lack of capacity and transportation barriers. 

Severe shortage of physicians and other healthcare professionals remains a notable barrier to healthcare access in Fangak county and South Sudan in general. According to the South Sudan Health Strategic Development Plan, there were only 3,946 categorized health professionals in the country. Provider-to-population ratios for selected high level categories include: 248 doctors (0.03), 1,193 nurses (0.13), 50 pharmacy staff (0.006), 34 dental staff (0.004) and 151 midwives (0.02). Provider availability largely influences healthcare utilization and access to treatment, and this is especially true among resource-limited rural communities. The growing discrepancy between supply and demand presents a crucial challenge to healthcare access in Fangak. Delayed access to healthcare services in the health centers is due to shortage of qualified providers. Most patients who need acute and lifesaving care face exceptionally long wait times before being able to see a provider. Prolonged wait times have been shown to be associated with increased morbidity and mortality as well as decreased patient satisfaction.

 Lack of availability of transport means, geographic distance, and high cost presents another significant barrier to gaining access to healthcare services in Fangak given that there are no primary roads that run through the county or that connect it to the neighboring towns. Patients travel by foot or boats to distant health centers within the county. Those who need specialized care have to travel several hours and sometimes days to Malakal town (120 km), Bor town (324 km) or Juba (474 km) mostly through unsafe water transport and occasionally by air. Greater travel distance to medical centers hampers frequent healthcare utilization and worsens health outcomes. These transportation barriers become more problematic to women, children, elderly, and physically handicapped population groups who have restrictions on mobility, lack decision-making autonomy and live below the poverty line. 
South Sudan’s 2013 political unrest coupled with economic meltdown has critically impeded the effort of the government to develop basic infrastructure in the health sector. As a result the government has relegated its mandate, the delivery of essential healthcare services to international development partners and NGOs. NGOs are now responsible for almost 80 percent of health service delivery. However, NGOs and external partners remain poorly equipped to deliver short-term essential healthcare services, and offer sustainable solutions to the healthcare challenges in the country.

Our solution is a hybrid telemedicine - a physical-digital model that blends virtual visits with rapid point-of-care testing. We establish remote telemedicine centers in communities in dire need of healthcare services. A center consists of the following; i) a consultation software connected to internet-enabled medical devices, supported by a video consultation system for remote patient-physician interaction, ii) a diagnostic laboratory to provide rapid point-of-care testing and  iii) an optional pharmacy or drug vending machine. In communities with either limited or no access to reliable internet connectivity, and unavailable or too expensive electricity grid, our centers are connected by the satellite internet and powered by a solar micro-grid. The solar system is also used to pump underground water for the center. The center acts as the most peripheral, first point of contact between the primary healthcare system and hard-to-reach communities.

Centers provide Remote Doctor Consultations which entails the entire process of medical consulting and diagnosis to bridge remote connectivity between doctor and rural patients. The consultation system has the ability to connect up five physicians simultaneously for case reviews. Other features of the consultation system include; i) access to patient triage and medical history with one click, ii) access to the patient appointment and prioritizing schedule based on the case type and urgency, iii) doctor assessment and diagnosis compliance with ICD-10 Codes, iv) on-line prescription and generate Doctor’s reports and v) referral pathways. The consulting doctor can order laboratory tests and dispense prescriptions through the center-based laboratory and drug vending machines respectively.

Our remote health center is equipped with telemedicine-enabled devices like the e-Stethoscope, ECG, Blood Pressure, Glucose monitor and Pulse Oximeter, etc to measure the vitals and update the patient medical records with the same. This remote center is connected to remote doctor’s consultation via a cloud based telemedicine exchange server, a cluster of video consultation servers communicating with Health data exchange server and medical records repository. Patients at our remote center (Spoke), can consult with the specialist at the Hub, our hospital partners on a state-of-the-art video consultation platform. The consultation process between the patient at our remote center and the physician is initiated by our medical assistants. When patients visit our center, our medical assistants register, capture and update their preliminary information, vitals, and medical history and schedule the doctor’s appointment by sending the invite to the doctor for a video consultation. 

Our centers also have a diagnostic laboratories and an optional pharmacy or drug vending machines to provide rapid point-of-care testing and dispense prescriptions respectively so that the specialist at the Hub can order laboratory tests or e-prescribe medicines without the patient traveling to the hospital. Operated by locally recruited and trained medical assistants, medical techs (IT support) laboratory technicians and/or drug dispensers, one center can serve up to 5,000 people. The entire operation in the centers is monitored by a single remote smart dashboard to gauge optimal working conditions of both the software and hardwares such as the power, internet, electronic medical devices, etc.

Our primary target populations are women of reproductive age (13-to-46 years), under-five children and persons living with disabilities in rural and internally displaced persons’ camps in Fangak county. Majority of women of reproductive age in Fangak cannot read or write with only a few having basic literacy. They have limited access to smartphones and are not connected to the outside world via the internet. Communities in Fangak county are primarily agro-pastoralists with most families below the poverty line. According to 2020 population projections, Fangak county hosts more than 190,000 people of which 36,428 are Internally Displaced Persons (IDPs) and 22,355 returnees (2019). But following the 2023 Sudan ongoing civil war, the number of returnees in Fangak certainly increased given the fact that more than 600,000 South Sudanese refugees in Sudan returned to South Sudan. 

Mothers and persons living with disabilities in Fangak face systemic, geographic, gender, income and disability barriers to access healthcare. Access issues compound when barriers overlap and individuals become part of more than one of these groups. For example, many women and girls face significant restrictions on mobility and lack of decision-making autonomy to access healthcare. Unpaid caregiving and childcare disproportionately fall on women, leading women to put the needs of their family members above their own. Women are also more likely than men to be uninsured and live in poverty. Lack of nearby health facilities has meant that sick mothers, children and girls have to travel alone for several hours or even days to access healthcare, which puts them at greater risk for sexual and gender based violence. Long distant in-person medical visits are often a challenging undertaking for patients with severe disabilities. The burden of traveling, coordinating, managing limited mobility, and ensuring safety make seeking care a challenge for disabled individuals and their caretakers. Given the scarcity of healthcare services in Fangak, patients have longer commute times, fewer care options, and don't visit doctors as regularly. They receive little to no preventive care, and tend to present for care in the later stages of their diseases. As a result, these categories experience worse health outcomes and higher death rates.

Most rural patients in Fangak county had to travel long distances only to find that they could be cared for remotely. Our community-based telemedicine centers provide acute and emergency care to mothers, children and disabled persons without the need to travel long distances. Women are also turning to our services for triage care for sick family members. Our providers evaluate patients remotely to determine if they need transfer for in-person specialized care. When there is a need for transfer, our referral pathways minimize issues created by care fragmentation by improving communication and coordination between care providers. Our hybrid services are aligned with the national health priorities, of reducing the high maternal mortality rates, improving child health, and addressing infectious diseases. 

Our team is capable of creating change because we are qualified, talented and passionate about using technology to improve health outcomes of hard-to-reach communities. 

Our team lead, Gatwal Yul has both medical and humanitarian background. As a child, he grew up in Fangak until 2002 when he was force displaced by the Sudanese civil war to a refugee camp in Uganda, where he studied up to university. In 2017 Gatwal returned to Fangak to establish a nonprofit that provides livelihood programs to hard-to-reach communities in Fangak and Uganda refugee camps. Gatwal and his family were greatly impacted by the chronic shortage of healthcare services both in Fangak and as refugees in Uganda. Gatwal was inspired by his firsthand experience in working to provide solutions to underserved communities to co-found the Upper Nile Institute in 2022 to enable equitable access to quality and affordable care for the hard-to-reach population in East Africa.

The support staff at the telemedicine center are recruited and trained locally. They include mainly the medical assistants who initiate the entire e-consultation with the doctors, medical techs, and lab techs. They have a complete understanding of their community including cultural norms. They speak the same language as locals and translate during the consultations. This brings ownership of our initiative to the community we serve. Although medical providers are outsourced from different parts of East Africa, we ensure that they are experts in diseases endemic to the community or area they are assigned to and familiar with the people's basic ways of life. 

We co-designed our initiative with considerable participation of the communities we serve; from problem exploration to solution space using basic tools like the design thinking and visual facilitation to attain a problem solution fit. For example, to set up a telemedicine center in a remote community, we first assess their healthcare priorities so that services are aligned with community needs. Then, we assess population size and the walking distance or time to determine where to establish the centers. For the solution space, a benefiting community is engaged right from the value proposition design through prototyping to piloting.  Community is also involved in designing the programs’ theory of change and continuous quality improvement activities. We engage communities through meetings, focus groups, surveys, facilitated workshops, interviews and other feedback mechanisms.

We have achieved a problem-solution fit that include; 1) evidence that our customers care about the job i.e when patients fall sick, they want to see qualified healthcare provider immediately so that they can get affordable and effective treatment; and pains such as traveling long distances and its associated costs, delay in seeking care and subsequent high disease burden. 2) we also designed a value proposition that addresses the job and pains and creates gains. We have ascertained that our hybrid healthcare services; virtual visits and point-of-care testing are actually creating customer value and getting traction. When we set up 2 pilot centers in Juaibor payam of Fangak county in South Sudan and in Kiryandongo refugees settlement in Uganda 7 months ago, we initially used whatsApp and zoom calls to connect doctors to patients remotely. Customers show strong desire for our services compare to the alternative solutions such as traveling distance to get care. To date, we have served at least 550 paying patients in both centers. 

Telemedicine is a new industry in East Africa with limited infrastructure and support systems. I am applying for Solve to gain access to ‘curated opportunities to connect & network with impressive peers that act as a trusted support group, offering inspiration and guidance.’ If chosen for the Fellowship, my aim is to acquire valuable skills and knowledge from this community. Specifically, I aspire to enhance my resource mobilization capabilities, encompassing pitch deck development, proficient pitching skills, and the formulation of effective go-to-market strategies. Additionally, I seek guidance in shaping and refining our venture's value proposition and business model, constructing a comprehensive iterative testing roadmap, and mastering the synthesis of evidence for the creation of crystal-clear, evidence-based presentations with key insights. Upon program completion, my goal is to become an integral part of a meaningful networking opportunity and a community of practice that provides access to not only funding and investment opportunities but also continuous learning.

The adoption of telemedicine in rural and hard-to-reach areas in South Sudan and East Africa in general is inhibited by high cost and lack of public infrastructure. Before care is offered through telemedicine, health care organizations must invest in the necessary resources to conduct patient visits. Factors such as the lack of electricity and internet connection has hampered provision of telemedicine services in these areas. As a result patients have to travel long distances for in-person medical visits which is costly in term of transport and time taken. 

Our project is innovative in our opinion, because it uses solar mini-grid in areas where there's no electricity and satellite internet in communities with no access to reliable internet connectivity. By using this innovative approach, we will enable access to quality healthcare services for all in hard-to-reach communities. 

Our 3-year objectives and key results

Objective 1: Provide 45,000 people with hybrid medical services.
Key results:
1. Establish 3 telemedicine clinic in South Sudan and 1 Medical Hub in Uganda.
Key initiatives/ activities:
Conduct market research to identify untapped regions/ demographics with high demand for telehealth services.
Customize marketing strategies to address the specific needs and preferences of diverse geographic segments.
2. Expand tele-consultation services from 3 to 10 medical specialties and subspecialties.
Key initiatives/ activities:
Develop strategic partnerships with healthcare providers, insurers, and other stakeholders in key markets.
Make consultations, laboratory and pharmacy services readily accessible from the mobile apps.
Hire and train 15 physicians, 30 medical assistants, and 10 med techs on clinical and technology skills.
3. Achieve more than $700,000 revenue and 13% profit margin.
Key initiatives/ activities:
Mobilize $500,000 from an external fundraising campaign drive.
Generate $200,000 internal revenue.
Streamline key processes to reduce operational costs.

Objective 2: Improve health outcomes of 100,000 rural and hard-to-reach people.
Key results:
1. Decrease under-5 and mother mortality rate by 5%
Key initiatives/ activities:
Implement tele-triage to prioritize urgent cases.
Collaborate with healthcare professionals for virtual multidisciplinary consultations.
Provide community with promotive and preventive health education.
2. Reduce recurrent rate to 1%.
Key initiatives/ activities:
Conduct follow-up and check-ins to assess patient progress and address any emerging concerns.
Continuously analyze data on illness recurrence to identify trends and refine preventive strategies accordingly.
Implement regular health education programs to enhance patient understanding of preventive measures.
3. Attain 75% patient adoption and engagement.
Key initiatives/ activities:
Provide educational resources to guide patients to maximize the benefits of e-consultation services.
Develop a user-friendly app/ platform with appointment reminders, e-prescription management, and follow-up.

Objective 3: Optimize healthcare utilization in rural and hard-to-reach communities.
Key results
1. Guarantee a 15 minute average waiting time.
Key initiatives/ activities:
Keep the IT infrastructure up-to-date to minimize technical glitches to ensure a seamless connection experience.
Conduct regular clinical and technology skills training sessions for providers on e-consultation best practices.
Regularly analyze data on teleconsultation waiting times to identify bottlenecks and continuously improve.
2. Attain a 95% improvement in operational efficiency.
Key initiatives/ activities:
Streamline appointment scheduling, registration, and payment processes to reduce waiting times.
Optimize the platform infrastructure to handle increasing user-load without compromising performance.
Implement automated systems for medical record retrieval, reducing administrative burdens on providers.
3. Achieve 90% customer/ patient satisfaction rating.
Key initiatives/ activities:
Conduct regular clinical and technology skills training for staff and providers on telemedicine best practices.
Implement regular quality assurance surveys and feedback mechanisms to assess patient satisfaction levels.
Analyze feedback data to identify areas for improvement in the consultation process, usability & patient support.

Full time: 7

Part-time: 13

2 years