Telehealth is the use of electronic information and technologies to support long-distance healthcare services from healthcare workers to patients remotely at any time and place. Bangladesh is a developing country with only 6 doctors per 10,000 patients11. The healthcare sector is heavily focused in Dhaka, the capital city of Bangladesh; although 64% of the population resides in rural areas, and patients need to travel long distances to access healthcare services1. Telehealth is allowing healthcare workers to see patients virtually in locations that were not accessible previously, and this has reduced cost and time as well as saved lives. With 60.3% of the total market as of 2019, North America is currently the largest telehealth market and is expected to remain so until 2025; however, the Asian market is predicted to grow fast1.
Bangladeshi Telehealth practices began in 1999 through the Center for Rehabilitation of Paralyzed (CRP) by Swinfen Charitable Trust of the UK, which used store and forward-based telemedicine with digital cameras for taking images, but no real-time technology was applied. However, lack of marketing, poor logistics, and little connectivity meant that this approach did not succeed. In 2020, the COVID-19 pandemic led both government and non-government bodies to initiate telehealth for delivering patient care all over the country. Through a public project under the Directorate General of Health Services (DGHS), high-quality telehealth services were established at Bangabandhu Sheikh Mujib Medical University and the National Institute of Cardiovascular Diseases with 3 district hospitals (Shatkhira, Nilphamari, and Gopalganj) and 3 sub-district hospitals (Pirgonj, Dakope and Debhata) 1. Among private projects, Praava Health, Evercare, Maya, and Telenor Health are some of the successful hospitals and organizations leading telehealth services in Bangladesh.
Although few people used telehealth services in the pre-COVID-19 period, the pandemic has led to a significant rise in telehealth services in Bangladesh. Covid-19 testing rate in Bangladesh during the initial outbreak was only 0.34%, the second lowest in South Asia, only after the war torn nation-Afghanistan. This also led people to stay home and seek medical assistance through virtual channels as many wanted to prevent the virus11. During the pandemic, a rising percentage of individuals in Bangladesh are turning to telehealth as it may provide more convenience and access to care for online consultations while minimizing the risks of virus transmission that may result from going to a healthcare provider. This study will leverage a timely national experiment to evaluate the impact of telehealth across the Bangladeshi population. Despite the overall growth in telehealth in this country, it is unclear whether telehealth utilization has increased for patient populations for all age groups and both genders in 2020 and whether there has been any impact labor market productivity. The research question and hypothesis are as follows:
Research Question:
What impact did telehealth use have on patients productivity in the labor market in Bangladesh during the COVID-19 pandemic in 2020?
Hypothesis:
Telehealth usage led to higher labor market productivity for patient users in Bangladesh during the COVID-19 pandemic compared to patient users who chose in-person doctor visits in the 2020 pandemic.
Significance of research questions:
Telehealth use is experiencing unprecedented growth. However, telehealth users’ demographics are unclear in Bangladesh. The research question aims to assess the demographics and impacts of telehealth use on labnor market productivity compared to in-person appointments with healthcare providers for healthcare utilization.
Conceptual Framework
The conceptual framework shows hypothesized associations of socioeconomic and demographic factors that affect health outcomes. In the socioeconomic and demographic factors, the phenomenon indicates a patient’s absolute and relative position in society, including prestige, education, occupation, and wealth. For example, employment provides income, which influences choices of housing (residential and community), relationships among friends and family, food, medical care, and more. However, employment depends on education because the higher the education a person attains, the better employment opportunity he/she will typically receive. Employment sometimes depends on the gender/sex of an individual, considering there is a glass ceiling for women in Bangladeshi society. For example, females often experience discrimination in the job market and often receive less payment compared to men in the same position.
Socioeconomic and demographic factors lead to varying health outcomes for patients because the higher the income or education the better health literacy he/she possesses and also the better health care he/she can seek, leading to improved healthcare utilization. Having a good job also leads to employers covering the cost of health insurance. Patient safety and patient experience outcomes are tied with income because patients with higher income can afford expensive treatments in elite hospitals. Many dimensions of social relationships, such as access to social networks and availability to emotional support, can be important to health through healthcare utilization, clinical processes of care, cost, and patient experience. This is usually identified through marital status, social support, and living alone. Residential and community context indicate housing, walkability, broadband coverage, access to transportation, safety, and proximity to services. Patient experience will include communication with nurses and doctors, access to timely appointments and information, the responsiveness of healthcare staff, care coordination, pain management, medication information, and overall experience.
In terms of resource use outcomes, cost and quality of health depend on which part of the region the hospital is located in as well as how expensive the treatment is (better or expensive treatment can be afforded by patients with higher socioeconomic status). For example, patients residing in Gulshan area of Dhaka City, usually turn to United Hospital, which is expensive but has one of the highest rankings in terms of quality, whereas patients in Old Dhaka area might turn to Capital General Hospital, which is cheaper but has one of the lowest rankings in terms of healthcare quality. Also, hospitals using telehealth services will likely see reduced admission rates and mortality in patients, and patients will also incur reduced healthcare-related costs (e.g., transportation costs). However, rural populations might not have sufficient internet access and might not be able to utilize telehealth services in comparison to other populations. Simultaneously, health care outcomes directly affect the resource use outcomes, mainly through high administrative costs, costly new technologies, expensive drugs, and physician fees. However, if the patient seeks telehealth, then the costs are likely to decrease as telehealth leads to improved patient outcomes through advanced monitoring, cognitive affordances, execution of life-saving, and evidence-based critical care protocols. Moreover, telehealth increases the ability to access timely care by reducing potential travel issues or transfers to other health care facilities.
The government of Bangladesh has declared it will fix fees for healthcare services in private hospitals, and this will lead to reduced cost of care, while improving quality of health12.
Literature Review
Telehealth usage during the COVID-19 pandemic has become one of the vital tools for patients to seek medical assistance. While there are a few studies regarding its utilization in Bangladesh, none of them have incorporated demographic and socioeconomic aspects of the Bangladesh populations. Uscher-Pines & Mehrotra (2014) analyzed the overall impact of telehealth by Teladoc, where only 7% of the patients had follow-up visits compared to patients who visited physicians’ offices or emergency departments (ED) for similar conditions 2. Another study by Uscher-Pines et al., (2020) assessed how telemental health is deployed through semi-structured 60-minute telephone interviews with providers and found that 48% used a range of services3. In a comparison study between quality and access to care at Teladoc using claims from 18-64 years old enrollees in a state, it was found that 3,043 patients used telehealth services 4,657 times (Uscher-Pines et al., 2014), but Teladoc is only on-demand telehealth care and has a gap in addressing other types of telehealth3. A study between March to April 2020 conducted a semi-structured interview with 20 outpatient psychiatrists with COVID-19 cases and patients who experienced satisfaction using telehealthcare services, but the inability to observe nonverbal cues, limited bandwidth, and incompatible devices were some issues for underserved patients4. The Diabetic Association of Bangladesh (BADAS) provided telehealth to children and adolescents with type 1 diabetes through phone calls and text messages, where 235 patients received advice over the phone from March to April 2020, and 52% of them were from the capital city, Dhaka 5. Most of the patients experienced hyperglycemia and were advised accordingly, and the study recognized telemedicine as a solution for routine care of diabetic children who are unable to travel long distances to clinics.
Rural Bangladesh has good acceptability for telehealth, with a mean age of 32.38, a monthly income of approximately 9000BDT, and a maximum of 17 years of schooling 6. However, no study has been conducted involving both rural and urban parts of the country to assess telehealth efficacy. Usability issue is one of the barriers in telehealth adoption; 61% of usability problems contributed to slow adoption of mobile health usage 7. But this paper only examines mobile applications and could be extended to other forms such as web applications.
Systematic reviews showed that telehealth interventions produce positive outcomes when they are used for remote patient monitoring, especially for chronic conditions (e.g. cardiovascular and respiratory disease) and psychotherapy (e.g. behavioral health), with improvement in mortality rate, quality of life, and reduced hospital admissions, reduced patient time in emergency departments, reduced heart attack mortality during emergency services and improved access and clinical outcomes for outpatient consultations8. Moreover, research in telehealth should be integrated with new models of payment and care to assess the continuum of care in organizations. A paper studied four years of data from a nationally representative biannual consumer survey of telehealth use trends and the role policies play in its usage9. As Bangladesh is a developing country, there are several challenges including digital divides and disparities, and the equipment facilities in e-health services for both patients and healthcare providers should be increased, along with making separate laws and reimbursement policies for physicians and patients10. Currently, the physician cost of telehealth and in-person visits is the same in most hospitals and clinics.
Some studies have overestimated the rates of telehealth use as it was conducted online and so excluded people with limited internet access, and there was the possibility of self-reported bias as the data was retrospective. Moreover, policies need to be made to incentivize providers and health systems to use telehealth even after the pandemic, such as offering financial incentives to providers to adopt telehealth. For example, Kaiser Permanents Medical Group gave a complimentary iPhone and data plan to all 9000 physicians to support telehealth use and counts telehealth visits similar to in-person visits. Furthermore, the removal of financial consumer barriers to using telehealth for low-income populations can enhance telehealth visits. This can include implementing waivers or discounts to purchase needed equipment such as smartphones, data plans, or sufficient internet coverage. Misinformation and lack of communication networks made the healthcare system crumble, vulnerable and incompetent. In such chaos, national media outlets failed to efficiently and effectively deliver reliable information to the audience from all walks of life, letting the more personalized and internet-based occupy the communication space11. However, there is insufficient broadband coverage in most of the rural areas, posing further challenges to telehealth usage. It must be noted that even if telehealth service is widely available (i.e. during the COVID-19 pandemic), some rural patients might not have complete information on how, when, and where (through which platform) to use it. Therefore, improving education and awareness in underserved communities can increase overall health outcomes. The Ministry of Health in Bangladesh can mobilize investments to improve telehealth infrastructure and provide enough access to such populations and underserved communities.