There is a new kind of hospital in town. Patients do not have to pay for transportation to get there, allowing those who live outside big cities to access medical specialists at short notice.
Waiting times are slashed by over 90% in most cases, and patients have the autonomy to communicate with their doctors at a time most convenient for them. Once the consultation is over, patients can receive their medication without setting foot in a pharmacy. All of these realities exist within the four walls of the patients’ own room. In fact, anyone can hold this hospital in their hand. This apparent utopia of healthcare is telemedicine.
Telemedicine is a modality of healthcare delivery that uses technology for the exchange of medical information. With internet connectivity and electronic devices like smartphones or computers, anyone can consult a doctor in real-time regardless of their geographical location.
Take, for example, Doctor Raksa, currently Thailand’s #1 telemedicine application which was founded in 2016. Once you download the app and sign up, you can choose from a list of online doctors to consult with. You will have the option of texting, voice calling, or video calling your doctor for at least 15 minutes at a price four times lower than a visit to private hospitals.
Next, you fill in the information regarding your symptoms and can attach a photo if desired. A few minutes later, you will have access to your doctor who can provide consultation and, if needed, an e-prescription for medication which will be delivered to the patient’s address within two hours. Thanks to Doctor Raksa’s revolutionary mobile-based healthcare service, 76% of issues are resolved after the first doctor consultation.
Doctor Raksa Platform
Telemedicine is also being utilised for mental health counselling. Ooca is Thailand’s top tele-mental-health platform which breaks down logistical barriers to accessing counselling while helping to support the careers of dedicated mental health professionals
Currently, over 100 psychologists and psychiatrists (accounts for 5% of those registered in Thailand) cater to 80,000 registered users on the platform, with about a thousand users active every month. To access the service, you can book a 30-minute online counselling session with either a psychologist or psychiatrist. You can choose up to three problems you want to discuss, and the system will match you with an appropriate specialist.
Just like an in-person visit, the doctor takes the patient's history and symptoms, performs an examination, and may recommend treatment. Further, for those who are unsure about whether they need help, Ooca offers a free stress-test.
Contactless Healthcare for a Contactless Society
Since the beginning of the pandemic, Thailand has consistently ranked among the highest in terms of COVID-19 response and continues to defy the odds with its deliberate public health measures.
At the time of writing this article, Thailand had only 3,575 recorded cases despite its proximity to China and the fact that its capital has been the most internationally visited city in the world for four years in a row. It had also enjoyed over 100 days of zero community transmission. While many factors contribute to Thailand’s success, collective efforts to provide contactless healthcare by both the public and private sectors have played an important role.
In what is dubbed as the ‘New Normal Medical Service’ by the Royal Thai Government, hospital visits have been minimised by utilising digital technologies. The recent Pattani Model classifies patients into three 'traffic light' groups – green, red, and yellow – based on their need for direct medical care and risk of COVID-19 infection, with green being the lowest risk. Patients that do not need to visit a healthcare facility are supported by remote consultation (telemedicine) and drugs are delivered to them, often by village health volunteers, thus reducing hospital congestion and infection rates.
The acting director of Thaicharoen Hospital in the Northeastern Thai province of Yasothon recognised the convenience of telemedicine when he said, “Normally patients in rural areas are faced with financial constraints as hospitals are usually scarce and they have to pay beyond their means to visit the hospital, even to get their dose of monthly medicine. Now hypertension and diabetes patients can just wait and have their medication delivered to their houses."
Village Health Volunteers
Photo credit: https://www.sdperspectives.com/csr/aorsormor-ais/
Collective Response to COVID-19
Telemedicine is, in fact, only a subset of telehealth services. Telehealth allows long-distance patient and clinician contact, care, advice, reminders, education, intervention, monitoring, and remote admissions. It is essentially a more comprehensive form of digital healthcare. During the pandemic, all dimensions of telehealth are employed collectively by the public and private sector to respond to this international health emergency.
For instance, Thailand’s National Innovation Agency has partnered with public health agencies and the HealthTech Startup network to open up telehealth services to the general public and healthcare professionals. AI-powered health information, online hospital search, appointment system, self-screening, COVID-19 Patient Under Investigation (PUI) follow up, teleconsultation, patient care, medication intake reminder system, and medical equipment transportation are a handful of the services provided.
Doctor Raksa contributed to the fight against the COVID-19 outbreak in Thailand through their cooperation with the Thailand Tech Startup Association (TTSA) and the Ministry of Public Health in providing information and screening. Doctor Raksa works with partners to deliver telemedicine services to people who are far out in rural areas. Village health volunteers visit different homes to check villagers’ conditions and identify cases suitable for telemedicine. Through the “Ped Thai Soo Pai” (Thai duck fighting the pandemic) Facebook page, volunteering doctors team up to offer primary screening and consultation via the Raksa app.
Mental health problems, likewise, don’t go unnoticed during the pandemic. Ooca works with the Child and Adolescent Mental Health Rajanagarindra Institute to provide its platform as ‘Software as a service’ (SaaS) to help hospitals go virtual at a time when hospital visitation can add another layer of stress to people seeking medical care.
The Role of Telemedicine in Reducing Healthcare Inequality
“In rural areas, it is difficult to gain access to timely healthcare. At present, there are provincial hospitals and primary care facilities, but one is geographically inconvenient and another doesn’t always have doctors. I think telemedicine will be very helpful for people in remote areas because we won’t have to travel long distances to wait in a crowded hospital from 2-3 AM only to see a doctor 10 hours later. This way, villagers will not have to miss work and lose their daily income.” - interview with a CSO officer based in the north of Thailand.
Barriers to healthcare still exist against the backdrop of Thailand’s Universal Health Coverage, underscoring inequalities between big cities and rural areas. Statistics reveal that despite 70 percent of the population living outside of Bangkok, 70 percent of specialists practice in the capital city. This is where telemedicine shows promise of bridging the healthcare access gap by cutting hospital visitation costs, expanding access to specialists, and saving patients time in their busy lives, all at the comfort of their own homes.
Though the fee for most private healthcare telemedicine services is already much lower than that of typical private hospital visits, Ooca has taken it a step further by offering free counselling services through their pay-it-forward model called Wall of Sharing.
Wall of Sharing aims to create mental health awareness and offer free counselling services to students, especially to those attending public universities. “We believe in building an equal society where everyone can have access to quality mental health care. As we understand that not everyone will be able to pay for the service of Ooca, we pioneered ‘Wall of Sharing’ by twisting our business model to balance donations with reduced therapy fees.” - Ooca Founder.
The Ooca team successfully convinced a majority of the psychiatrists and psychologists in their platform to reduce their consultation fees by 80% as a contribution to this voluntary effort in working with young people in need. The remaining fees are covered by donations from people who believe in Wall of Sharing’s mission.
With an understanding that mental health stigma acts as a barrier for care-seeking in Thailand, Wall of Sharing regularly promotes conversations about mental health on social media. Scrolling through their Instagram page or Facebook page, you will find content such as self-care tips, inspirational quotes, information about different mental health conditions, online workshops, and interactive games.
Ooca’s Wall of Sharing
Photo credit: https://readthecloud.co/wall-of-sharing/
Reaching the Last Mile
As the effectiveness of telemedicine services rests upon existing medical and public infrastructures such as the supply of doctors and current technological capacity, there are still healthcare access gaps that cannot yet be closed.
Enabling everyone to use telemedicine seamlessly will not only require access to the internet, which currently reaches just 72% of the Thai population, market education and health literacy are also crucial. Shockingly, research by The World Bank shows that one-third of 15-year-old Thai students are ‘functionally illiterate’ or they read so poorly that they struggle to understand the meaning of what they have read. The problem is particularly acute for students enrolled in village schools in rural areas, where almost half are functionally illiterate.
Basic literacy is the foundation of health literacy and subsequent digital health literacy skills. Since telemedicine is still a novelty to most people, without the awareness and knowledge of how it can be used to improve their quality of life, people will remain solely reliant on the traditional care model.
Another important factor is access to banking, which is also marred by regional disparities. Payment in most telemedicine platforms similarly follows the contactless principle as does the rest of their functionality. This means people who are not registered in any banking service cannot use telemedicine. A study by the Bank of Thailand reveals that even though over 90% of Thai households overall had better access to financial services than in 2016, the majority of households with no access to financial services were low-income and those living in the Southern and Northeastern regions.
The co-founder of Doctor Raksa shared that they welcomed support from the government to truly reach remote areas, “If the Ministry of Public Health has any initiatives to help more people in the rural areas, we would love to help. Telemedicine could be a good disease screening tool and help keep patients out of the hospital. Doctors will also benefit because of reduced congestion. In the current care model, almost everything is done in the hospital. In the future, we should aim towards distributed healthcare. If there is government subsidisation to compensate telemedicine doctors, maybe as part of universal health coverage, the doctors will be more willing to come online.”
Reaching the last mile of seamless access to telemedicine means addressing the problem of health literacy and increasing doctors' fee subsidisation, together with improving internet and financial access at all levels of society.
A Magic Pill to All Health Problems?
As promising as it sounds, telemedicine may not be the panacea for all health problems. At least, not just yet. Currently, only 70% of outpatient consultations can be replaced by virtual healthcare. What we will do, or even, whether we want to increase that percentage depends on our priority setting.
Further, the limitations of virtual healthcare do not only apply to physical health issues. A user of an online therapy platform shared the following about marriage counselling and the future of teletherapy: “Though a lot of work happened outside of our virtual therapy session, we experienced personal growth and discovery. The counselor encouraged us to think about things we did not realise before. However, there are some physical mannerisms I do which the doctor may miss while communicating with us, such as nervous foot tapping. Moreover, in Thailand, mental health is still stigmatised, so even though mental health services are available, people may not see the value of therapy. I think there is more work to be done in mental health awareness before we get to the issue of improving access to cutting-edge health technology.”
Another point to consider is that diagnosis and treatment afforded by telemedicine are usually the last stops on the healthcare continuum. Improving access to medical care may not be the most effective measure for lowering health inequality for two reasons. Firstly, there is the importance of the social environment and lifestyles (social determinants of health). And secondly, the aetiology (causation) of the most common causes of mortality and disability almost always involves processes accumulated over the life course.
Therefore, to really nip health inequality in the bud, preventative measures such as anti-smoking campaigns or vaccination programmes are not to be overlooked, especially in the wake of a global pandemic.
Health For All, All For Health
Telemedicine has immense potential to reduce healthcare inequality, but equally pertinent, are concerted efforts from multi-sectoral stakeholders to move the proverbial needle. Earlier this year, Wall of Sharing posted about the term ‘Meliorism’ on their social media. It’s the belief that the world can be made better by human effort. As we are transitioning into a future shaped by the global pandemic, it’s high time that we, as Changemakers, work together to meliorate our healthcare system into an achievable utopia for all.
The author would like to thank Anisha H. for her valuable mentorship, Anna C.M. for her meticulous proofreading work, Joy A. and Nada C. for introducing the author to the interviewees, and all of the interviewees including Doctor Raksa and Ooca founders who contributed their insights on telemedicine.