TOWARDS SDG 3: Telemedicine as a service, bridge to universal health coverage

The Government of Ghana has ambitious goals for universal health coverage by 2030, but the outcomes stand a great chance to be missed without leveraging digital health, especially in the areas of health infrastructure, human resource, service quality, and health data aggregation. Ghana’s Ministry of Health (MoH), working together with its agencies and partners, has the task to develop and coordinate the government’s policy decisions toward solving these challenges. The ministry’s policy directives in this regard are various and noteworthy, except the fact that there exist a gaping policy gap to be plugged, using digital health solutions. Telemedicine, as a service, promises to be one such optimal solution to the rescue.

The MoH deploys a 4-year rolling strategic plan dubbed: ‘Health Sector Medium-Term Development Plan’ (HSMTDP) which it evaluates in collaboration with its agencies, development partners, and civil society stakeholders. The goal of the plan is to increase access to quality essential healthcare and population-based services for all by 2030. The policy objectives of the current plan (HSMTDP, 2022-2025) are those set out to tackle identifiable gaps that emerged following the assessment of the impact and development outcomes of the previous plan (HSMTDP, 2018-2021). The table attached represents some of the relevant outcomes during the 2021 review of the previous medium-term plan.

Source: Performance Review of the 2018-2021 Health Sector Medium-Term Development Plan

The parameters in the table represent some of the key social development indicators that were set in 2017 under the four policy objectives of the previous mid-term plan. Following the 2019 performance evaluation of the programmes and activities of that plan, the HSMTDP 2018-2021 was assessed to have achieved an overall score of 2.9 (on a scale of 0-5). This outcome set in motion the key development issues and challenges to be addressed by HSMTDP 2022-2025, as is currently under implementation. Out of the three policy objectives set out in this current plan toward achieving the overarching goal by 2030, the number one objective is captured as: universal access to better and efficiently managed quality healthcare services for all. Further to the policy objectives are specific key priority concerns that are called out in the current plan to be addressed. Some of these will include:

• Inequity in access to essential health services and variability in the quality of services
• Inequitable distribution of human resource for health
• Inadequate health infrastructure, logistics and equipment
• Sub-optimal quality of care at all levels of the healthcare system
• Lack of national database for health data

The complementarity of telemedicine offers optimal solutions for inclusive health systems

The use cases of technology as complement to traditional systems continue to evolve across various industries, except telemedicine where it remains not one of the most popular technology adaptations in Ghana as yet. Telemedicine, as a service, provides alternative voice or video medium by which a patient or the public can reach and receive medical consultation and other ancillary healthcare services from a licensed medical practitioner – as a subscription based service or as pay-per-use service. Professional telemedicine services are set up to provide centralised systems of healthcare service delivery, via highly secured technology infrastructure, where qualified health professionals and specialists are able to provide undifferentiated levels of medical consultation to patients, irrespective of whether one is located in the high-ends of Cantonments – Accra, or the socially deprived village of Kulungugu – Upper East Region.

Telemedicine is not a substitute for traditional hospital care. It has some advantages; but more importantly, it complements traditional systems of health service delivery. It brings to practitioners and patients alike some optimal benefits that traditional healthcare alone may not offer. Saving transportation cost and travel time to hospital, saving time spent in long queues at the hospital, and having unrestricted 24-hour access to the doctor via phone will make the obvious advantages that many people will ascribe to a telemedicine service. The most advantageous benefits of telemedicine are those that streamline the technical and professional aspects of healthcare delivery.

Lower cost of healthcare: A significant factor that inhibits the inclusivity of the health systems is the cost of healthcare. Be it via medical insurance or out-of-pocket, healthcare is priced above the income levels of most Ghanaians, for which reason many would not attend the hospital, even when they feel unwell. A subscription-based telemedicine service is one that cuts out the overheads of a brick and mortar medical facility, thereby allowing for significantly cheaper pricing of healthcare services. The fee charged for one-off doctor consultation at most hospitals in Ghana would typically be equal to the annual pricing for unrestricted multiple consultations with a doctor via telemedicine subscription.

Quality Improvement review on doctor consultations: There are frequently recorded cases of wrongful diagnosis widely reported around the world. According to a 2018 study by Dr. Martin Makary of John Hopkins University School of Medicine, more than 250,000 people in the United States die every year because of medical mistakes, making it the third leading cause of death after heart disease and cancer. In the traditional hospital environment, this may be the case because medical doctors may not have the privilege of quality reviews by their seniors or colleagues when they go about their work in the consulting rooms. In contrast, professional telemedicine set ups allow for live listening in by senior practitioners on all doctor-patient conversations, and all the interactions are automatically recorded for review purposes also. Quality Improvement teams of senior medical consultants will have access to the recorded consultations which are played back to evaluate doctor performance and further training where required. These interventions make for significant reduction in the issue of wrongful diagnosis and/or medication prescription by medical practitioners.

The proactiveness of healthcare and wellness: The Ghanaian approach to health and wellness will normally not be one of proactive medical review. Telemedicine service algorithms are those that make for proactive outbound doctor engagements at various intervals of the customer experience journey of subscribers. These are prescheduled doctor consultations woven into the fabric of the telemedicine service providers’ technology infrastructure, allowing for frequent doctor interaction with subscribers. For instance, upon onboarding onto a professional telemedicine service, a doctor’s welcome health and wellness call will go out to the subscriber where a comprehensive review is undertaken to ascertain subscriber’s medical history and present state of health, and also offer medical education as may be required by the subscriber. Many such proactive outbound doctor engagements will continue with subscribers at pre-established cadence throughout the life of the subscription. These kinds of interventions are those which help in building a health-conscious society, a healthy people, and healthy nation!

Follow-up doctor calls post consultation: The nature and practice of traditional healthcare is not one that allows for the hospital facility to follow up with patients after hospital attendance. Indeed, the practice is for doctors to encourage patients to visit the facility for review after a certain period. It is widely known that 99 percent of people do not go back once they feel a lot better. Among the reasons for this situation is the consultation fee charged by the facility when the patient shows up for the review. On the other hand, professional health-tech platforms which run telemedicine services will have in-built Patient Management Systems that automatically activate outbound follow-up reviews with patients at set intervals post initial medical consultation. In most cases, such systems are intelligent and flexible enough to allow the practitioner to set up the follow-up review to a date and time of the patient’s choosing. Patients tend to enjoy quality continuity of care toward total recovery.

Seamless management of chronic diseases: The protocols around managing chronic disease conditions can be difficult to adhere to by patients, their caregivers, and even the medical practitioners who administer the protocols. Managing such conditions require high level consistency of care administration from practitioners, and even higher levels of adherence to the protocols by patients and their caregivers. The absence of these cause complications that lead to further deterioration in the state of patients’ health, and death becomes imminent. Telemedicine set-ups allow for seamless management of chronic conditions; where practitioners design specific technology-enabled avenues by which specific health conditions (diabetes, hypertension, stroke, cancer, etc.) are managed for optimal benefits. This is achievable via two-way engagements which are automatically triggered at specific milestones via multiple touchpoints (mobile apps, IVR, text messaging and live calls) to ensure efficient continuity of care from practitioners, and adherence to protocols by patients. Such well-developed condition management architecture will embed health coaching programmes for patients, continuous medication delivery at home, daily reminders for medication, remote self-help patient monitoring test kits and test result reporting systems, etc.

Undifferentiated access to specialist care: Until the need arises for one to consult with a specialist medical practitioner, many typically will not appreciate the scarcity of such services within the health systems in Ghana. In situations where they exist, they are mostly concentrated around Accra and some regional capitals, thereby exposing the rest of the country to the gods and their charlatans. Telemedicine, as a service, makes a good equalizer, democratising equal access to various forms of specialist care: clinical psychologist, psychiatrist, dieticians, pediatricians, gynecologists, etc.

Access to personal health data and consultation history: The sight of stacks of paper files, popularly known as ‘hospital folder’, arranged on shelves, and kept sometimes in open corridors is rampant across many hospitals in Ghana. These folders, containing the patient’s health information, will typically not be accessible to the patient whose information is contained in there. However, somehow, sometimes, these paper stacks will find their way on the streets thereby exposing patients’ confidential health data to the public. Telemedicine provides optimum security of patient’s health data as all patient-doctor engagements are kept digitally, and access to the data being easily available to the patient via various electronic means. The quality of patient’s historical health data – including conditions diagnosed, lab results recorded, medications prescribed, and dosages administered, as well as the dates of all consultations – will remain undiluted and secured. These become extremely important for quality continuity of medical care even where the patient transitions to a traditional hospital facility for further care.

Customer experience (CX) and quality check surveys: Aside from live listening-in and quality checks on recorded consultations as will be undertaken by senior medical practitioners, telemedicine service providers will mostly deploy another layer of quality check on their service delivery. This time, the quality check is assessed from the point of view of the patient. Various types of customer surveys are undertaken using varying media so to cross-verify the quality of service delivery at every customer touchpoint within the clinical patient management value chain. Customer surveys may take the form of standardised questionnaires administered by the CX team to measure specific key parameters (like NPS, CSAT/DSAT scores), or ad hoc one-off surveys to gauge the pulse of patients at a particular point in time. For instance, some service providers will embed an automatic quality check IVR that is activated at the end of every doctor consultation, requiring the patient to select (key in on their phone’s touchpad) their level of satisfaction (on a scale of 1-10) with the just-ended consultation. The results of such quantitative quality checks are immediately available to the CX team for their instantaneous analysis and further decision-making where required. Other surveys will take the form of direct phone calls by the CX team to patients so to ascertain some nuanced qualitative information for further analysis and service improvement purposes. The point is, professionally set-up telemedicine services go all length to ensure optimal quality of medical care for their patrons.

Discounted price offers from partnerships with offline service providers: A subscription-based telemedicine service (be it stand-alone service or affiliated to a traditional hospital facility) will typically have partnerships with offline service providers like laboratories and pharmacies. These partnerships will be underpinned by signed SLAs between all parties in the health service delivery value chain. Underpinning these partnerships will be strong technology regimes that allow for seamless service delivery. Mostly via API integrations, patient data are securely transferred between the partner service providers in real-time, thereby allowing the tele-doctor enough information during the medical consultation process. Further advantages that lead to the benefit of patrons will be the discount offers which are mostly negotiated with the partner service providers: laboratories, pharmacies, medicine delivery service providers. The telemedicine service provider will typically rely on its subscription-base to negotiate some rebate on the cost of the partner’s service delivery to the subscriber-base of the telemedicine service. These become savings in the pockets of the patrons of the service, making life a little easier for them.

Aggregating national health database: Perhaps the most important benefit that accrues from widespread adoption of telemedicine to complement traditional hospital facilities is one that goes to government and its policy-makers. The absence of reliable national health data militates against government’s efforts at designing social policies that respond appropriately to the health, wellness and livelihood needs of the people. By the click of a button, the built-in algorithms of telemedicine set-ups are able to provide vast array of nuanced health datasets of its subscriber-base. The agility and dexterity of these set-ups will make for quicker and more accurate aggregation of national health data for sound analysis, further research, and much responsive and sustainable policy-making. Ultimately, the multiplier effects of the resultant benefits to the economy, medical businesses, the health sector, and the people, will be massive for inclusive socio-economic development.

Telemedicine as value-added-service (VAS), the next frontier of deepening product differentiation and distribution within financial services.

The development of telemedicine services and the other peripheral systems and business models it will activate cannot be left to the health system or its practitioners alone to grapple with. To achieve the scale required to meet Sustainable Development Goal 3 (SDG-3), the channels by which telemedicine as a service is distributed will become the important lead measure of success ahead of target date 2030. By heeding the call to action of SDG-17, the service can benefit significantly from the wide reach of customer touchpoints that other industries within the services sector of the economy provide. For starters, telemedicine makes a seamless VAS that, when bundled with other industries’ product suits, will enhance customer stickiness and reduce churn. This evolving frontier of product integration by benefit-bundling is timely as customers across various industries continue to demand tangible, life-enhancing, product benefits from their service providers.

Banks: Just as bancassurance has evolved to become a mainstream revenue line for banks, so does telemedicine as VAS (call it ‘bank doctor service’) promise to become the next frontier of banking evolution in Ghana. The agility of the service and the portability of its infrastructure makes it a good fit for bundling with banks’ products, or for distribution as a stand-alone proposition by the banks. The banks benefit as it generates a new revenue line for their operations while customers also enjoy optimal benefits from one-stop shop services.

Medical insurance: Averagely, OPD claims contribute about 80 percent of total claims payout of medical insurance companies. Aside laboratory investigation and pharmacy services, the cost of doctor consultation makes a significant chunk of the OPD claims expense. Correspondingly, these come together to make the largest contributor to the cost build up for health insurance policy pricing by underwriters. By bundling telemedicine services, and positioning it as the first point of non-emergency call by the insured, medical insurance providers are able to significantly reduce the cost of their services. More affordable premiums make a sustainable medium by which more people are able to indemnify their families against medical vulnerabilities.

Life insurance: The appreciation for the benefits of life insurance propositions remain low, for which its patronage is not as encouraging in this part of the world as it is elsewhere. One reason being that its benefits are not as tangible as those of other financial services. Rationally, people would have natural affinity to products that provide ‘living benefits’ in their lifetime than those that pay out benefits after death. Telemedicine, as a bundle, provides tangible benefit propositions that increase customer stickiness to retail and corporate life insurance policy propositions. Ultimately, this goes to solve the age-old challenge of policyholder retention for life insurance underwriters.

Telecommunication: Mobile telephony technology has enjoyed the quickest adoption and the largest penetration rate among Ghanaians since its entrance. It is an industry that has perfected the concept of VAS as a means to build strong affinity to its service propositions. From mobile technology as a voice communication service to metred Internet as a service; and further to P2P, C2B, and B2C payments as a service, this industry continues to evolve at customer stickiness levels – unmatched by any other. The next frontier of telecommunication evolution is the integration of telemedicine as a bundle to existing solutions, or its adoption for distribution purposes only. Considering the industry’s penetration rate at above 100 percent of the population, their collaboration augurs well for the universal health coverage that Ghana pursues.

Conclusion

Arguably, Goal 3 of the United Nation’s Sustainable Development Goals – ensure healthy lives and promote well-being for all at all ages – is one of the most fundamental of the 17 goals. Much so because it promotes inclusiveness in health coverage, which is a basic need for all persons, akin to the universal declaration of human rights. Generally, Ghana continues to score modest milestones relative to the 17 goals, yet there remains room for exponential growth in performance against the set targets, especially that of Goal 3.

With the rapid evolution of technology and the high penetration of mobile phone services, Ghana stands well-positioned to adopt telemedicine as a cost-effective and convenient means by which it can accelerate its policy outcomes for universal health coverage by the 2030 target date. Indeed, the convergence of financial services and telecommunication services create fertile grounds for portable integration and distribution of telemedicine to reach every Ghanaian located anywhere in Ghana. The potential benefits that accrue to all stakeholders from the widespread adoption of telemedicine in Ghana promises to be limitless. Ultimately, no Ghanaian is left behind.

The writer is a long-standing player in financial services (Banking, Insurance, and Pensions Administration) and digital health (Fintech/Insurtech and Telemedicine Administration). He is an advocate for Financial Inclusion and Sustainable Development. Email: [email protected]