The Challenges of Health Hotlines

Some of us remember a time before the internet, before Google and Wikipedia, where seeking medical advice of any sort meant a trip to the doctor, a long wait in the clinic, followed by five minutes of consultation (and potentially, a large bill). This is still a reality in rural areas of many developing countries, except the trip to the doctor would mean facing overcrowded health facilities and a painful loss of critical income due to time spent on the road.

Health hotlines potentially remove that for the user, with the added benefit of removing excess demand for the health system, so they can focus on genuinely serious problems.
When it comes to health matters, the opportunity to speak to a health professional on demand is always highly valued, as GSMA’s mNutrition Consumer insights study across eight countries revealed. Health hotlines was consistently ranked first or second before other typical mHealth services like messaging or insurance. However, the concept faces several challenges that are similar in most markets and are made even more evident at scale-up.

1. Regulation on tele-diagnosis: In most countries if not all, health regulations and policies favour one-on-one interaction between health personnel (doctors, nurses, consultants) and patients. To reduce the risk of misdiagnosis, a medical consultation requires the patient to sit in the same room with the doctor. This is to allow the doctor to observe the patients for any additional symptoms that that the patient may exhibit, in addition to what the patient tells the doctor. These visual cues will normally help health personnel probe the patient further, especially if the obvious symptoms (fever, cough, rash) are shared by more than two or three different distinct illnesses. A conversation over the phone is therefore considered inferior and frowned on by the medical establishment.

If the law only permits general advice, without diagnosis or prescription over the phone, then the value of the call from the user perspective becomes a challenge. In emergencies, getting advice that could save a life (e.g. “bleeding during pregnancy is a danger sign, please go to a hospital immediately and don’t waste any time”) is great value from a hotline. But, “that sounds like a flu, please take adequate fluids, but we recommend you go see a doctor in case it is anything more serious”, may feel like it wasn’t worth making the call for, as the call still did not replace the need to visit a hospital. Additionally if the call was at a premium rate, then the user has to pay for it, and still pay to visit a health facility to be attended to.

2. Lack of health seeking behaviour: Technology goes viral if it enhances the efficiency of an existing behaviour. The urge to communicate, and the limitations of fixed telephony, set the stage for mobile technology to flourish. With mobile, we can talk when and where we want. The same principle applies with mHealth. If patients already value health advice, a mobile application to deliver the advice to them becomes appealing. If a user is already conscious of their diet or fitness, technology to aid in this (fitness app, wearable, online subscription to training videos etc.) is an easy sell. If as a habit you visit a doctor on the onset of symptoms, then the ability to contact one immediately becomes a compelling reason to take on a service. If, however, patients in the market you deploy a health hotline to, only consult a doctor when critically ill, the demand and frequency for the health hotline is likely to be low. If the average users consult a doctor once a quarter or less, then a potential market size of one million people is effectively reduced to a fraction of its potential in actual service demand due to the existing health seeking behaviour.

How do you get the users to begin “seeking” this information? Most phones today come with a health app embedded and free, but that does not translate into usage by phone owners. It would take influence from a user’s immediate environment to alter health seeking behaviour. Unfortunately in most cases, a diagnosis of a health condition is what leads to improved health seeking behaviour e.g. Cancer, Tuberculosis and Diabetes. In the absence of a diagnosis of a condition, users may not find value in paying to access health information or a consultant at other times.

3. Problems with business models at scale: Successful business models are able to balance value for money for clients, as well as cost and revenue for the business. Health hotlines are require to be manned by trained personnel, and often specialists depending on the kind of calls received or how specific the call centre is e.g. HIV or maternal and child health (MNCH) call centre, or general health. What does it cost to run the call centre, and how do you spread that cost across fluctuating peak volumes? Do you charge per call or volume pricing, do you charge before or after the call? To charge per call, normally per minute, would require that your call fee is able to cover cost plus a margin. Let us look at the costs incurred during a call: communication cost, call centre seat/terminal, and the professional responding to the call. If the average cost of a medical consultation is USD 10 for anywhere from a 5-20 minute visit to a doctor, you could average it to USD 1 per minute or less. Is it reasonable to charge a user USD 1 + margin (to cover cost of infrastructure) per minute when the user calls the health hotline? If the market is not receptive to this fee, then the business model is unsustainable.

If from the above discussion the customer is charged per call, they may consider it too expensive and shun the service. If a normal call on the network is USD 0.04 per minute, but the call to a doctor is USD 0.60 (X15 higher) or more, the per minute model risks being considered exorbitant, despite access to professionals, and the need to cover costs including the doctors fee. If the service is billed volume, e.g. per month or per year, consumers may begin to question the value if they go for six months without needing to call a doctor, despite having pre-paid. On the other hand, if the service does not receive a decent volume of calls per day (for the per minute charging model), or if customers fail to renew the monthly subscription model (volume or per month model) the business is not able to afford paying specialists and skilled professionals, which may further erode the value perception by customers, and ultimately lead to the service being shut down.

In a later blog, I will discuss strategies and options that have been used to overcome some of these challenges, and pave the way for sustainable health hotline services.

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