Karibu Tele-Daktari

Half of the world’s population cannot obtain essential health services, and to access even basic healthcare in remote communities of sub-Saharan Africa (SSA) requires a walk of hours, even days. With 59% of Sub-Saharan Africa still living in rural areas, the community members most impacted are the continent’s poorest, often living below the international extreme poverty rate of $1.9 a day. For them, walking to a health facility steals valuable time away from income-generating activities, whilst the alternative, paying for transport, is unaffordable. Patients turn instead to traditional remedies that worsen health conditions, and additionally prevent health authorities from identifying the primary diseases and health challenges facing remote populations. In Guinea, it took nearly three months for health officials and their international partners to identify Ebola virus as the causative agent, as sick patients were unable to easily seek professional help.

A more accessible, affordable healthcare infrastructure is essential for improving uptake by remote patients, leading to better general health and disease prevention. Unfortunately, the conventional method of scaling, by building and staffing new clinics, is expensive, slow, and further hindered by the deficit of health care professionals in rural/remote areas of developing or low-income countries. Although telehealth is a familiar ad successful concept for increasing healthcare convenience and cost in urban settings, its direct application in remote, unserved populations is hindered by low digital literacy and unavailability of medicine locally - Only 45% of the population in Sub-Saharan Africa subscribed to mobile services at the end of 2019, and the majority of these would have been from urban areas.

We’ve seen these challenges first-hand, working with doctors and Maasai communities in Northern Tanzania, where patients, especially pregnant women, mothers with young children, and eldery patients, struggle to travel to their nearest healthcare clinic to seek medical help. We will be developing our solution in these Tanzanian communities, where doctors and health officials have expressed to us the limitations of their current infrastructure.. However, our research shows that the same challenges are faced by remote communities in developing countries across sub-Saharan Africa and beyond, making any solution easily adaptable for use elsewhere.

We have identified that the majority of people in these remote rural communities have low levels of literacy and IT awareness, and often only speak local languages (in the case of the Maasai in Northern Tanzania they often do not speak or understand Kiswahili, the official language). Our research with healthcare practitioners both in Tanzania, Nepal and Uganda, has shown that many telehealth solutions and apps rely on a degree of sophistication in IT use, and ability to understand English or at least the national language.

In addition, our research across multiple countries suggests that often telehealth applications operate independently of national healthcare systems. This means that “regular” doctors may struggle to access diagnoses or data from telehealth apps, and that national health insurance or payment systems may not work. This is a particular problem both for end-users, doctors and health authorities who may be seeking information or statistics on rural health issues.

Our approach is designed with simplicity in mind, and tries to integrate into the “regular” national system of healthcare as much as possible. In each community, a pop-up telehealth hub, containing basic diagnostic equipment and a video conferencing device, will be run by 2 local, trained operators, at a fixed time each week. Patients will have diagnostic measurements taken digitally and sent to their doctor in the nearest town/city, followed by an entirely remote video consultation with their doctor, who is familiar with the community and will speak their language. The trained operator, with gender matching the patient, may assist in facilitating the call where necessary due to digital literacy. Prescribed medication for several patients can be delivered from the nearest pharmacy in batches on motorbike or by drone in extreme cases, with the long journey to the doctor only required in emergencies and for specialised tests, significantly reducing unnecessary transport times, costs and effort for the patient.

Since access to energy or signal may often be a challenge in the remote communities, we pair this with a small scale sustainable energy system and internet connection (for example via satellite broadband or microwave relay). Additional small energy services (such as phone charging, or hairdressing) help offset the cost of these facilities so that the healthcare users do not have to pay for it.

Patients will pay for remote consultations in the same way as for standard healthcare, with increased uptake and improved consultation efficiency enabling the new service, including additional operator’s salaries, to be financially viable.

Across SSA, 59% of the population is rural, and 40% live on less than $1.90PPP a day. Rural, remote communities are usually a country's poorest, without access to healthcare, so by targeting these unserved populations we are helping those most in need. In SSA, 15.9% of adults aged 60+ have a journey of over 2 hours to reach their nearest healthcare-facility, with some countries having statistics as high as 59.4%, whilst 9.6% (5.2 million) have a journey of over 6h to reach a hospital. Our innovation targets these remote, rural communities across SSA and beyond, namely Tanzania where our research is based, but we believe the same approach can be adapted and scaled across the continent and beyond. Typically these countries have resource challenges, making our low cost, minimal-infrastructure approach appealing, and more likely to result in faster access to healthcare. 

The solution will serve groups such as the Maasai, marginalised for cultural, geographical and socio-economic reasons, and especially benefit individuals for whom travel is challenging. This includes disabled community members, elderly patients, pregnant mothers and mothers with young children. Women in these communities traditionally do not have financial independence from their husbands, and often struggle to pay for transport to access health services, instead staying close to home to care for their children. Our preliminary trials highlighted this demographic, with 80% of attending patients being female (indeed most young women turned up with a young child/baby that they were responsible for), 50% of patients being over the age of 40, and 32% under the age of 15. By bringing access to healthcare to their community at an affordable price (oftentimes free for those covered by the national healthcare system, or holding a medical insurance card) without the need for costly, or time-consuming transport, sick community members will be able to quickly and easily seek medical advice without it negatively impacting their finances, or responsibilities, leading to improved healthcare outcomes.

SVRG was founded in 2017 to research and develop technologies and business models for more holistic approaches to development of rural communities in the global south. For example, to address the priorities of the whole community in an integrated way (encompassing eg energy, water, health, education, gender) to produce solutions which have a greater cross-cutting impact and longer-term sustainability and scalability than “standard” solutions which only address a single SDG. Since 2017, working with more than 15 international partners across 8 countries, our current projects have developed and tested innovative approaches to energy access, clean water, cold storage, rural business incubation, crop value addition, rural remote education, remote healthcare and irrigation. 

With numerous links to NGOs and research organisations across developing countries, we are well placed to initiate roll-out of a developed solution at scale across continents. We work through several female-led teams - indeed more than 80% of our workforce is female. Together, we have more than 25-years experience of international development, and have run projects to a total value of more than £8m in the past 10 years. 

Working with our long-standing partner, OMASI, a Maasai community development NGO in Northern Tanzania, we have conducted over 11 types of end-user engagement activities across 4 rural maasai communities with 200+ participants to verify the community healthcare needs and priorities. We have gained the support of several in-country rural and city doctors, the Simanjiro district health officials, International Health NGO ‘CACHA’, UK Telehealth provider ‘ConsultantsConnect’, and global non-profit ‘World Telehealth Initiative’. We have also engaged with Sharon Allen, currently serving on the World Health Organisation Digital Health Board of Advisors and Roster of Experts, working on their Telehealth Roadmap for the Underserved.

In 2021, partnering with local doctors in Northern Tanzania, we ran preliminary video consultations to test the concept with patients, giving valuable insights into additional equipment requirements. Following the success of these tests, we ran 4 telehealth clinics, each 1 day long in 2 different communities, with over 50 patients treated, and many more turned away due to time-constraints. These trials demonstrated additional challenges relating to prescription management, operator training, and healthcare advertising, but we were able to adapt our approach to improve the service each time. Patient and doctor feedback was overwhelmingly positive, with all requesting the service to be made permanent and more widely available. We are now working to develop this solution that the community clearly values and are continually asking us for progress updates whilst we implement our other development projects in their area.

We believe we have a solution which has potential to radically improve healthcare access for millions of remote community members, and in turn improve general healthcare outcomes, whilst providing health authorities with more data on health challenges facing remote communities. However, this is the first time one of our innovations has been ready for scaling, and as a consequence, we lack experience in preparing convincing business models, and persuasive pitches to present to senior health officials and world health NGOs. 

We would like mentorship through our next set of pilots to improve on our monitoring and evaluation strategy, and how these are translated into a convincing proposal for scaling. Our ultimate goal is to partner with governments and NGOs to roll this out across continents, but first we need more impact evidence, and credibility. In addition, due to the limited resources available to many healthcare departments in developing countries, it is likely that a significant amount of start-up investment will be needed in the initial ‘growth’ phase. Through coaching from experts and the Solve and MIT networks, we aim to improve our fundraising success rate, enabling us to present to governments not only a persuasive pitch, but also a zero-cost, zero-risk preliminary roll-out for evaluation.

The technology we are currently using for patient data transfer, video consultations, and medicine prescriptions, is very basic, based on existing social media technologies. Although this is beneficial as it enables the method to be easily adapted based on need, and does not require existing hospitals/health centres to be using a specific software, it does have limitations on efficiency and security. Consultants Connect have offered free use of their teleconferencing technology currently used by the NHS in the UK, but it would require significant simplification and translation to be effective for use in rural populations. We hope that Solve may help us connect with software engineers that may be willing to support us in either adapting this existing software, or developing a much simpler system specific to our intended solution.

Finally, exposure in the media and at conferences will help us build our network and get advice from more healthcare and country-specific experts. This will give credibility to our organisation and solution when pitching for support of widespread rollout in the future.

The healthcare-technology field is a very popular and fast-moving one. But the vast majority of solutions are aimed at rich clients in the industrialised world. Solutions for the developing world have, in our experience, often focussed on technically basic solutions, such as electrifying clinics, innovating medical recordkeeping solutions, or providing (complex) remote diagnostic tools that nevertheless require a trained medical professional to operate them.

There are few innovations that seek to tackle an issue as broad and fundamental as general access to healthcare, with a solution as simple and scalable as ours. From more than 7 years of interest in this field, and research, there are no directly comparable to this innovation in the market, which can access rural communities without high levels of digital literacy, who may not even speak the national language. Bespoke teleconsultation systems have been trialled, including in the Dominican Republic, that involve a degree of complexity that makes them very hard to operate and scale, since they are paired with so many complex diagnostics that the costs are very high and they require highly trained operators. The most direct competitor would probably be Babylon Healthcare, who offer a (much more complex) video-consultation app in the UK, and a much simpler SMS and audio-telephony-based system in Rwanda. Babylon's solution appears to be too complex and too profit-driven to have the bottom-up appeal and scalability of ours.

Yet using basic, facilitated video services and very basic diagnostic tools to offer effective teleconsultation systems for remote communities with poor digital literacy, has not been developed. These would either offer appropriate advice and diagnoses with medicine delivery in batches for several patients, or advise the sub-section of patients with more serious conditions that it is worth following this up with the expense and time of a face-to-face consultation or test. We believe this system would be an effective and easily scalable way of providing health coverage to remote communities, and of achieving a level of universal healthcare provision, which could then be iteratively complemented by either displacement with more traditional, staffed health facilities in a community or, alternatively, iterative improvement and development of the teleconsultation systems with increased medical functionality, without disproportionate cost consequences or training needs for the operators.

The only indirect competition would be from travelling health provision. This tends to be provided by NGOs in many countries. Mobile clinics can expand the reach of existing healthcare infrastructure, but require the doctor to waste precious time travelling, and leave their main hospital unstaffed for emergencies. With a shortage of healthcare professionals in rural areas, maximising doctors time is essential. Demand for mobile clinics is extremely high, with patients often waiting several weeks until they are severely ill before a doctor visits. Having a facility in the community which can be used regularly (or even immediately, in emergency) is preferable.

With partnerships with district health officials and existing e-Health service providers in Tanzania, we will ensure our solution will integrate into existing infrastructure, an aspect which our research has shown is too often not addressed by private telehealth providers.

Lack of electricity and good connectivity may have previously presented a barrier to entry, but our work in off-grid energy-access combined with recent developments in satellite broadband and microwave relay technology mean that we are well placed to exploit this opportunity now. Additional small energy services (such as phone charging, or hairdressing) help offset the cost of these facilities so that the healthcare users do not have to pay for it.

Our approach does not require the costly building and staffing of a new, permanent hospital, whilst enabling one doctor to have a much wider impact in his surrounding community. Simple diagnostic measurements taken by trained local operators will greatly increase the speed of a doctor’s diagnosis, allowing him to treat more patients faster. With remote consultations available once or twice weekly, patients can conveniently seek treatment earlier, reducing the likelihood of severe illness. Our solution will improve healthcare access and outcomes at a reduced cost, time and effort to patients, doctors and healthcare authorities.

To take our innovation further we have identified the need to run a number of 6-8 month pilots in 6 communities across Tanzania and Uganda (initially) followed by other countries we are initially targeting for roll-out (currently Nepal where we have conducted further in-depth research and connected with other healthcare and telehealth organisations). These trials would bring convenient, affordable healthcare access on a weekly basis to 80,000 remote community members who previously had little to no access to healthcare in their community. We want to run three pilots in Maasai communities of Northern Tanzania,  marginalised for cultural, geographical and socio-economic reasons. These communities would be the last to benefit from country-wide, traditional healthcare infrastructure improvements. Three pilots will be run in the mountainous communities of Western Uganda, where permanent infrastructural projects such as building a health centre is difficult to implement. From these pilots we will refine our business model, and collect rigorous monitoring and evaluation impact data, especially on health care outcomes and health data, to enable the model to be scaled. 

Our impact goal for the next year, especially with the mentorship and funding from MIT solve, would be to refine the plans and models for the pilot testing phase, including considering the M&E and data security in more detail and developing a better case for funding. That is why the MIT Solve programme would be so critical to our plans

Longer term, over the subsequent 4 years, we aim to run the pilots over the first two of those years, and then use the results to work with stakeholder - particularly national health authorities - to begin to roll the solution out officially, initially in a small number of districts in the countries before scaling up to the entire country and expanding to other countries.

Our primary goal through implementation of our solution, is for improved healthcare outcomes in remote communities (lower mortality rates over time). This will be achieved through a number of other measurable impacts:

• Improved access to healthcare for remote communities - reduced time, cost and effort for patient to seek advice from healthcare professional

• Increased uptake of healthcare services by remote communities – more patients seeking treatment earlier and recovering as result, rather than relying on traditional remedies.

• Improved awareness of healthcare issues in remote populations, leading to better lifestyle choices and healthier habits

For the solution to be scalable and sustainable, it must also have operational benefits to the healthcare authorities over alternative solutions:

• Increased income for health services due to increased number of patients, enabling further expansion

• Greater number of patients treated in same time-frame by a single doctor, due to pre-consultation diagnosis tests and efficient calling methods

• Development of basic operator training package, and generation of employment for local trained operators

• Reduced cost to health authorities for scaling healthcare access

• Increased data on healthcare challenges facing remote populations as more patients engage with the healthcare system, enabling better targeted healthcare campaigns and training

The following are specific metrics that we will take during our further testing of the telehealth systems:

1. # (and %age) of community that have used the new system as opposed to traditional consultations (SDG 3.7,3.8)

2. # of consultations held

3. Time and financial saving for community members from use of telehealth system

4. Specific statistics on treatment of (and successful outcomes) for maternal and child health, communicable and non-communicable diseases (SDG 3.1-3.4)

5. If study is long enough, a comparison of mortality and other outcomes compared with status-quo

6. Doctor satisfaction scores with system (related to SDG 3.c [retention of health workforce])

7. Community-wide data profile statistics for District Authorities (SDG 3.d [capacity for early warning and management of national health risks])

Outside the specific studies, an additional metric will be the number of international and national health stakeholders who indicate support for our solution and are willing to work with us to develop and test it further and roll it out.

Half the world's population cannot obtain essential health services (WHO & World Bank Global monitoring report, 2019), and to access even basic healthcare in remote communities of sub-Saharan Africa requires a walk of hours, even days (The Lancet, Geldsetzer et al. 2020). Smart Villages proposes a remote healthcare system tailored to remote communities in developing countries, aiming to make access to healthcare professionals more widely available to all.

In each remote community, a pop-up telehealth hub, containing basic diagnostic equipment and a video conferencing device, will be run by a local operator. Patients will have diagnostic measurements taken and sent to their doctor in the nearest town/city, and have their consultation entirely remotely via videoconference. Following the consultation, prescribed medication for several patients can be sent over on a motorbike, significantly reducing total transport time and costs.

We have already run several remote healthcare trials in remote Maasai communities in Northern Tanzania, with overwhelmingly positive feedback from patients. Over 70% of patients could be treated entirely remotely, and those needing an in-person follow-up visit were much happier to make the journey knowing that it was truly required. We expect this response to be applicable across Sub-Saharan Africa.

This solution is much cheaper for health authorities to implement than building and staffing new hospitals, and brings access to healthcare at a reduced cost, time and effort for patients. Our trials were oversubscribed, showing the high demand, and likelihood that many patients will seek treatment earlier and more frequently when access to healthcare is more convenient. This will lead to an overall improvement in health of remote populations, as illnesses are diagnosed and treated earlier and more effectively.

The telehealth system is dependent on 5 key technologies (alongside a supportive human-centred infrastructure to assist a demographic with low digital literacy):

1. Digital Diagnosis Measurements

• Measurements used to assist a doctor in his diagnosis. This can include but is not limited to temperature, weight, blood pressure, heart rate, blood oxygen, blood glucose etc.

• This technology is already well-established so we will use existing solutions in our approach. We aim to profit from digital devices designed to require very little operator skill or training, to improve the reliability of readings.

• We have already proven effective use of this technology in our preliminary trials, but there is scope to expand the offering to more complex measurements, including digital stethoscopes. These are likely to require greater operator skill, or have inbuilt feedback and be much more costly. We will not introduce these additional complex technologies into our preliminary offering unless we have generous funding, or have evidence that the additional measurements will make a significant difference.

Video/Imaging technology

• Enabling operators to take images and videos of the patients for the doctor to see. This is another well-established technology, available on all smart-phones and tablets.

Secure Communication Network

• For diagnosis measurements of patients to be sent to the doctor prior to consultation, and to facilitate video consultations.

• This is also an established technology, through WiFi and mobile data networks. However, it is widely accepted that connectivity in very remote areas is often poor. This situation is continually improving as governments push for widespread phone coverage, but it may yet provide some challenges for immediate widespread roll-out of the solution. 

• Alternative technologies do exist to facilitate internet connection when mobile data is insufficient. We have already successfully trialled microwave relay boosting internet in remote Maasai communities in Northern Tanzania, and believe that low-orbit satellite clusters will make rural broadband cheaper and faster in the coming years.

Data Transfer/Video communication technology

• This would be in the form of an app, enabling secure communication between the operator, patient and the doctor.

• Our tests conducted so far have been done using existing software (Google sheets, WhatsApp video calls etc.) to develop the system concept and requirements. Although an effective and easily adaptable solution, it may not align with security requirements in all countries, and so other approaches may be required. Our aim is to adapt existing telehealth applications with inbuilt patient data tracking and videoconferencing capabilities, for more general application in a rural setting. Existing telehealth app providers have offered the use of their systems for free, for this purpose.

Drug Delivery

• When a patient is prescribed medicine remotely, technology is needed to deliver the medicine. This will be done in batches to reduce the transport costs. In the most basic case, it will be in the form of a motorbike delivery. For more inaccessible communities (e.g. some of the mountainous communities we work with in Uganda), medicine delivery by drone may be more appropriate. Again this is a fairly established technology which has been used by relief organisations and is beginning to emerge as a use for telehealth.

Smart Villages Research Group is a primarily female organisation, championing female empowerment both within our organisation, and through the projects we implement abroad. Leadership of the organisation is shared between Dr Bernie Jones and Dr Anna Clements, ensuring values of both genders are equally represented. The organisation employs three female engineers, a female social scientist, and female accountant, being careful not to conform to gender stereotypes when people of different genders may be more suited to the work. We do not discriminate on geographical location (working remotely when in the UK), and are extremely tolerant of different cultures, race and national origin (we have employees living in Sweden and Switzerland, born in the Netherlands, of Chinese descent, and French citizens).

Our organisation and its values are grounded in a community-led, community-centric approach. Dr Anna Clements is a human centered design expert, and ensures that any of our projects are designed with the community's interests at the forefront. We begin any project with a thorough investigation into the community's needs and priorities, with multiple focus groups, separating women, men and youth, to ensure all individuals have the opportunity to speak out without fear. We run focus groups with women using only female facilitators to further prevent the likelihood of unintentional bias, and ensure the inclusion of every end-user’s opinion equally. This was done at the preliminary research phases of the telehealth project, and repeated as the design of the system was developed to ensure full community feedback was obtained.

We champion a participatory approach to design wherever possible, working closely with local partners in all projects to ensure cultural and social etiquette and norms are respected. In many cases, the projects we develop stem from an idea by one of our in-country partners, as they identify the need. We work with them to develop their solutions into something tangible, and enable them to take credit for and benefit from their innovation.

Product/service

Our particular new service will deliver simple access to healthcare to rural communities in Tanzania by providing a face-to-face teleconsultation link to a medical professional, backed up with simple local diagnostic equipment and basic medical recordkeeping integrated into the system. This system will give direct, local, low-cost access to healthcare to remote poor rural communities who have hitherto had no provision in the community, and have had to walk or travel long distances in order to access such services. This will also provide more complete population health data to district and national health authorities, as well as a faster and cheaper solution for them to achieve universal access.

We engage very deeply with our target communities, since we adopt a community-led approach including participatory design, ownership and management. We therefore have first-hand evidence of the importance that communities attach to access to effective healthcare, and the hardships and negative outcomes that go hand-in-hand with such access not being available (or the only local facilities being insufficiently staffed or resourced). Currently, there is no easy solution to be able to integrate into a holistic suite of technologies in order to deliver better access to healthcare in a community. Our expectation is that this new service will integrate well into our overall approach, and enhance its attractiveness to communities and funders.

Market

Nearly half the population of Tanzania remains below the income poverty line of $1.90 per day. With few resources, deteriorated facilities and a stunning shortage of doctors (just three for every 100,000 people), the government of Tanzania has long faced enormous barriers to ensuring equal access to healthcare for its people. 85% of the poor live in rural areas but they are served by only 28% of the country’s health workforce, and a mere 9% of its doctors.

So Tanzania’s severe human resource shortage disproportionately affects rural populations. Facilities nationwide on average were staffed with 13.1 health workers in 2015. Urban facilities had more staff (24.5 providers) compared to rural facilities (6.0 providers). And public facilities had fewer staff members than their (urban) private counterparts. There is a significant difference in healthcare provider ability as well. Across the country, health providers could correctly diagnose only 60% of five common conditions in a 2015 test. There was a significant difference between public providers in rural areas who managed to diagnose less than half (44%) of those conditions and those in the urban areas who correctly diagnosed 70% of conditions.

And these barriers are felt more particularly by women and disadvantaged groups. According to a 2018 study by the University of Tokyo, “despite agreement that access to healthcare must be universal and guaranteed for all on an equitable basis, women continue to face significant inequities in accessing and using healthcare particularly in low-income countries. 

In relation to the problems experienced by women in accessing healthcare, the following four major problems have been identified: obtaining permission (from family),  obtaining money,  distance to the health facility and not wanting to go alone (lack of spouse or family member escort). Having access to health consultations in the community significantly reduces all those barriers.

But studies show that caseload per healthcare provider and absenteeism are relatively low, so the issue in Tanzania is not over-burdened providers. The World Bank concludes that there “seems to be ample room for a significant increase in the caseload of Tanzanian providers, i.e. the level of productivity in health service delivery, without jeopardizing quality. In addition to increasing the volume of skilled health workers to address the shortage of providers, improvements in management, supervision and training is important to improving service delivery. But finally to improve the quality of healthcare it is important (the Bank says) that other measures such as the motivation of health providers be addressed.”

Yet people in Tanzania are used to paying for services.  Anything from schooling and water, through to electricity and healthcare. So people would be willing to pay for a service if it were available. And the government has a mandate to provide healthcare. The way this is currently implemented in unserved communities is that the community first has to build its own facility (a dispensary is typically the first step) and accommodation for a public health worker and they can then apply to the government to post a member of staff there, on a priority ranking basis. This is expensive for the communities and the government. An effective teleconsultation system of the sort that we are innovating would be a cost-efficient and rapid first step towards providing universal access, and would also provide health agencies with valuable data about particular health issues and needs in areas of the country that they simply have no detailed knowledge about, in health terms.

Competitor Analysis

The healthcare-technology field is a very popular and fast-moving one. But the vast majority of solutions are aimed at rich clients in the industrialised world. Solutions for the developing world have, in our experience, often focussed on technically basic solutions, such as electrifying clinics, innovating medical recordkeeping solutions, or providing (complex) remote diagnostic tools that nevertheless require a trained medical professional to operate them.

There are few innovations that seek to tackle an issue as broad and fundamental as general access to healthcare, with a solution as simple and scalable as ours. From more than 7 years of interest in this field, and research, there are no direct solutions comparable to this innovation on the market. Bespoke teleconsultation systems have been trialled, including in the Dominican Republic, that involve a degree of complexity that makes them very hard to operate and scale, since they are paired with so many complex diagnostics that the costs are very high and they require highly trained operators. The most direct competitor in Tanzania would probably be the App launched by the Aga Khan Hospitals, but this is for private healthcare and is mainly targeted at information provision, relies on a level of IT-literacy and equipment availability which is simply unavailable in rural communities, and does not integrate into local medical systems and pharmacies. 

Yet using basic IP-based video services and very basic diagnostic tools to offer effective teleconsultation systems have not been developed. These would either offer appropriate advice and diagnoses, or advise the sub-section of patients with more serious conditions that it is worth following this up with the expense and time of a face-to-face consultation or test. We believe this system would be an effective and easily scalable way of providing health coverage to remote communities, and of achieving a level of universal healthcare provision, which could then be iteratively complemented by either displacement with more traditional, staffed health facilities in a community or, alternatively, iterative improvement and development of the teleconsultation systems with increased medical functionality, without disproportionate cost consequences or training needs for the operators.

The only indirect competition would be from travelling health provision. This tends to be provided by NGOs in many countries (though in some countries, for example Brazil, there are travelling doctors in some provinces with very dispersed rural populations). Having a facility in the community which can be used regularly (or even immediately, in emergency) is preferable.

Technical/operational detail

At its heart, our service consists of the following components, some of which would be provided by us, and some by the community or the national health authorities.

• a community venue (eg a room) for tele-health consultations to take place

• high quality internet connection to the community

• teleconsultation equipment (a device with our system installed)

• simple diagnostic equipment

• a trained local operator of the equipment

• a willing medical practitioner with time to provide the expert link on the other end of the teleconsultation

• a willing pharmacy partner that can dispense necessary medicines and send them to the community

Financial model

The financially-sustainable model for being able to situate a solution like this in a community is something we need to fully explore and evidence in the next phase of the development of the service.

However, we know that

• Communities usually have a space that can be dedicated for community-benefit activities, even if only during a particular time of the week or day.

• Because internet connection and communication are important services to a community in general, we believe provision of the internet service to a community could be funded sustainably through a commercial business model (eg. selling connectivity by the week, or selling downloads).

• Patients pay between TZS 2000 and TZS 10000 to consult a medical expert in person (plus test fees). Alternatively, they can buy annual insurance for their whole family for TZS 30,000 that covers these fees. Our research suggests patients would still be willing to pay these consultation costs for a remote consultation as well, since they still save on the travel costs. Therefore the doctor’s time in teleconsultation is remunerated as normal.

We need to test alternative approaches for the cost of the equipment and the time of the local operator – either these could be funded by regional health authorities (since it delivers access to health care at a fraction of the normal cost) or NGOs, or alternatively patients or the community could be asked to pay a small premium to cover these costs themselves, as they are saving both time and money on transport by having access to a telehealth facility.

Training for the operator would be provided by the local medical practitioner, or the district health authorities (as well as ourselves)

Our research suggests pharmacies would be happy to aggregate together a day’s medicines, and arrange a motorbike to take them all together to the remote village, possibly even absorbing the transport costs within the cost of the medicines.

This commercialisation will allow us to grow our revenue from system implementation and operation as well as consultancy services. As a company motivated by social impact, our intention would be to reinvest profits back into rural development and health access initiatives and innovations.

We will not have the requisite evidence for commercially sustainable exploitation until after the next stage of development and testing.

For roll-out at scale, we intend to work with overseas governments to implement the solution in those communities most in need. This will provide a commercial opportunity for us in the UK as we sell the technology and our consultative services to governments and health authorities. As an innovation with potential to radically expand access to healthcare and improve patient outcomes in rural areas of the developing world, we also expect international health NGOs and donors to be interested in supporting the roll-out of the solution, assisting financially where governments may not have the resources to do so. Until the solution is fully operational and proven, we will rely on grants. Once the method has been proven, we will assist governments in raising investment capital to roll out the solution at scale. We believe this investment could be repaid over a number of years, through a financially-sustainability model situating the solution in the community, however, this is something we need to fully explore and evidence in the next phase of the development of the service. 

Through our research in Maasai regions of Northern Tanzania, we know the following:

1. Communities usually have a space that can be dedicated for community-benefit activities, even if only during a particular time of the week or day. The cost of using this space is likely to be very small, if not free, so should not prohibit the financial sustainability of the project.

2. Because internet connection and communication are important services to a community in general, we believe provision of the internet service to a community, if not already in existence through mobile networks, could be funded sustainably through a commercial business model (eg. selling connectivity by the week, or selling downloads).

3. Patients pay between TZS 2000 and TZS 10000 to consult a medical expert in person (plus test fees). Alternatively, they can buy annual insurance for their whole family for TZS 30,000 that covers these fees. Our research suggests patients would still be willing to pay these consultation costs for a remote consultation as well, since they still save on the travel costs. Some patients even said they would be willing to pay higher remote consultation fees, due to the reduced travel times and costs. Therefore the doctor’s time in teleconsultation can be remunerated as normal, and there may be additional funds available for the operators (on a much lower salary as unskilled workers). We expect that through widening of access to healthcare, many more patients will seek treatment, and thus the number of patients paying fees for the healthcare system will increase, further enabling operator and doctor salary payment. Through improved consultation efficiency (pre-consultation diagnostic measurements by lower skill workers) this should be within the capacity of existing doctors.

4. We need to test alternative approaches for the cost of the equipment and the time of the local operator – either these could be funded by regional health authorities (since it delivers access to health care at a fraction of the normal cost) or NGOs, or by device manufacturers as part of their CSR. Alternatively patients or the community could be asked to pay a small premium to cover these costs themselves, as they are saving both time and money on transport by having access to a telehealth facility. Due to the ‘pop-up’ nature of the telehealth hubs, the same equipment could be shared between multiple communities, and transported on motorbike on the days of operation.

5. Training for the operator would be provided by the local medical practitioner, or the district health authorities (as well as ourselves).

6. Our research suggests pharmacies would be happy to aggregate together a day’s medicines, and arrange a motorbike to take them all together to the remote village, whilst absorbing the transport costs within the cost of the medicines as they will have increased business through the telehealth hub. Patients have also said they would be willing to contribute towards the shared cost of a motorbike for medicine delivery.

This commercialisation will allow us to grow our revenue from system implementation and operation as well as consultancy services. As a company motivated by social impact, our intention would be to reinvest profits back into rural development and health access initiatives and innovations.

Our pilot tests in partnership with Maasai NGO OMASI, were funded through UK R&D grants (Innovate UK (the UK’s Innovation Agency), GCRF demonstrate impact in developing countries, round 1, phase 1, £86,400). Unfortunately, although the monitoring officers were extremely happy with the results of the phase 1 testing, they were unable to offer a Phase 2 round of funding due to UK aid cuts.

Since phase 1 testing we have been awarded a further grant of £30,000 from Foriegn Commonwealth & Development Office (UK Government’s Foreign Ministry) to explore international partnerships and collaborations to take this innovation further in Tanzania, Uganda and Nepal.

Our ultimate plan is for the system to be financially self-sustaining once fully implemented, with optional subsidies from governments, and health NGOs to reduce the cost to patients (as is done for the current healthcare system at present). During our most recent pilot tests in Northern Tanzania, patients happily paid for both medicine and the remote consultation with the doctor, showing that the system could operate financially sustainably if priced appropriately.