Back in December of 2018, I got tired of the high number of new telemedicine startups that kept launching in Nigeria. This was mostly because their predecessors had either pivoted, closed shop or became zombies. This lead to me writing a digital health newsletter with the title, ‘One too many’. In it, I outlined some reasons why telemedicine hadn’t taken off and why it would struggle for a while longer. I even went on to write a piece for Nigeria health watch suggesting other health startup ideas that people should consider outside of telemedicine. My sentiment toward the timeline for telemedicine adoption was succinctly captured in my closing words in the December 2018 newsletter:
it’s clear that the telemedicine race (just like most startup races) is a marathon not a sprint. All should prepare accordingly.
Well, Covid-19 has blown that prediction out of the water and has turned what ordinarily would have been a marathon into a sprint. A sprint for who will take the lead in the telemedicine marathon at a time when a lockdown and social distancing is in effect. The latter being likely to remain with us for a while yet. Seeing as I’ve knocked telemedicine in Nigeria (links to twitter rants against it) for a while, it’s only fair I review my stance in light of the new landscape and offer some thoughts and ideas along 4 themes that will affect how successful telemedicine will be.
Nigerians are extremely price sensitive at the best of times. This is especially so when it comes to healthcare and will be more pronounced with an impending recession. This reality means telemedicine will somehow have to fit into a reduced wallet and compete with important items such as food for people’s scarce Naira. To survive, telemedicine startups will thus need to find a way to insert themselves into some existing healthcare spend or replace that spend all together. This will not be an easy feat but, to my mind, is the only realistic option. Expecting patients to shell out an extra 1,000 naira for a remote consultation might be a huge step for many Nigerians in a covid-19 world.
Following from this tight wallet reality, chances are that with the retinue of telemedicine startups available, many will end up competing on price. This type of competition will end poorly with the likely death of many of these startups. Those that can figure out innovative ways to price especially via bundling with other health services will likely be able to escape the bloody waters of competition.
Technology adoption in Nigeria is still nascent. The average Nigerian isn’t particularly tech-savvy and the average health care user will be less so as they tend to be older. This poses a challenge for startups as they will have to grapple with educating their customers at tight margins. They will thus need to invest in well-designed technology that is familiar to the average user and is easy to navigate. In practice, this would mean designing for use via voice, USSD and SMS rather than video call or mobile apps.
The barrier to technology development continues to fall posing a challenge for how startups will differentiate themselves. It’s apparent to me that the competency will not be what technology you build (everyone will build with similar tools) but how you design it. How human-centred can your design be to remove all friction and allow super-easy adoption? This is where the winners will be found. Teams with designers and design thinking imbued within them stand the best chance.
The quality of telemedicine provided is going to be the ultimate basis for long term adoption. How startups assure this quality is thus going to play a big role in their survival. The first decision to be made is whether to employ healthcare workers directly or use a roster of part-time workers. Key for the latter is the process for selecting and vetting providers on the platform. Usual practices that apply in other jurisdictions may not be easily copied and pasted in Nigeria. For example, using just an annual practising license to vet providers may not be efficient as anecdotally, a significant number of practitioners do not undergo the annual process secondary to inefficiencies from regulators. Furthermore, these regulators unlike their colleagues in other countries, do not maintain easily accessible and searchable registers of their active professionals.
Beyond vetting, assessing the quality of the telemedicine visit itself proves a challenge. To do this, startups will need to ensure appropriate documentation. They may need to go further than just noting visit outcomes to recording and assessing full consultations in order to accurately gauge the communication and clinical skills of the remote provider. Will the professional be willing to allow a startup to have this level of oversight? It’s yet to be seen. There are further considerations on how they will correctly filter out cases that do not fit the telemedicine medium. Will they narrow down the nature of complaints/ diagnoses that can be seen and provide related quality care guidelines to guide the consultation?
A big elephant in the room is the continued brain drain of health professionals. With all the startups competing for the same dwindling pool, how will they assure staffing if adoption takes off? Will they be able to find professionals to hire at the experience level required for quality telemedicine? If part-time, will they get experienced professionals on their platform who are already overworked in their day jobs? All difficult issues that must be skillfully navigated.
Since COVID-19 broke, I’ve seen several corporate bodies offer free or low-cost telemedicine services to their customers or the general public. This tactic has in several cases been done in conjunction with a startup. This is a great B2B2C distribution play that allows the corporate partner to bear the initial cost of publicizing the service and/or giving the startup access to its customer base. A proposition that’s likely much cheaper than going direct to consumer.
Another good distribution play is selling into providers a white-labelled or branded solution they can use for their own customers. Back when I thought telemedicine would be a marathon, I thought it the best route. In this instance, it becomes a B2B service that health providers can deploy to their patients as they see fit. This route is an attractive one for companies that have existing health provider relationships. EHR companies, in particular, come to mind. A related channel is working with medical associations and societies to become their provider of choice. This significantly reduces the sales cycle and trust burden that startups face in B2B spheres.
Covid-19 has created a huge opportunity for telemedicine adoption that I hope startups can leverage in a way that lasts beyond the duration of the pandemic. Despite this opportunity, I’m still not particularly bullish on telemedicine as a standalone service. I’m, however, willing to be proven wrong and Covid-19 has provided the perfect opportunity. So to all the telemedicine people out there now is the time to get on your marks now and sprint to the head of the pack.