Bridging the Digital Divide: Early Reflections in Scaling Up Telemedicine in the Philippines During the COVID-19 Pandemic

Authors: Bernardo II Cielo 1, 2, Pura Angela Wee-Co 2, Aliyah Evangelista 3, Maria Eufemia Yap 2, and Matt Boxshall 2

1 De La Salle University

2 Strategic Purchasing for Primary Health Care (SP4PHC), ThinkWell

3 Knowledge Management and Information Technology Service, Department of Health Philippines

Telemedicine solutions have the potential to help address geographic and socio-economic inequities in accessing health care in the Philippines, but they have remained in the periphery of public health policy over the last 10 years. Outside the emergence of the pandemic, there already were significant cost barriers to accessing health care, particularly for low-income populations and populations living in remote areas. Adopting telemedicine solutions can reduce inequities as it allows for people to avail of health services otherwise inaccessible through conventional means of health service delivery. Local technologies that increase access to health services synchronously,  through telephony or video-consultations, or asynchronously, through tele referrals via  text messaging, have been implemented in different capacities over the years and have provided insight into how telemedicine can be mainstreamed in the country.

Uncertain government regulation of telemedicine has constrained its development in the Philippines. Donor-funded public sector initiatives were often small scale and were primarily treated as tangential services in support of the standard face-to-face consultation. Private sector interest has also waxed and waned over time and never really scaled as well. With telemedicine technology advancing at a rate which is difficult to keep up with, regulators feel that they lack the capability, capacity, and confidence to create and enforce policies. This delegitimizes the technology, which in turn creates discomfort in the consumer market. The lack of effective political prioritization, as manifested by poor public information, inadequate communications technology (ICT) infrastructure, and inequitable regulatory and financing levers, led to the slow development of telemedicine practice.

COVID-19 has further emphasized the need for effective telemedicine.  Following the decision of the Philippine government to implement lockdowns in response to the increasing spread of COVID-19 in early March, seeking health care services became increasingly difficult. At the same time, the fear of catching the virus from these health facilities altered health seeking behaviour. Health facilities, who were already operating at full or over capacity as health care resources, were reallocated to concentrate on responding to the growing pandemic.

The Department of Health (DOH) responded to this challenge by establishing a telemedicine ‘sandbox.’ Together with the National Privacy Commission (NPC), two policies were issued which enabled a no-cost partnership arrangement with telemedicine providers to offer free COVID and non-COVID related consultations during the pandemic in Metro Manila. The engagement was treated like a regulatory sandbox, where the DOH was able to closely monitor and learn from the implementation to strengthen its regulation. For telemedicine providers to be engaged, they had to secure certification from NPC and DOH that they are compliant with current privacy and quality standards. Engaged telemedicine partners were advertised to the public through an official COVID hotline, and in return providers were required to submit their utilization data to DOH for the duration of the engagement. At the onset, two providers participated in the sandbox, and another three providers joined in succeeding months.

The pilot implementation so far illustrates the potential strengths and limitations of how telemedicine can expand the accessibility and efficiency of health service delivery, even in a post COVID-19 world. The first two telemedicine companies who participated in the sandbox reported operating at full capacity and provided approximately 50,000 consultations over a three-month period, mostly through telephony. Some of these even came from outside Metro Manila and only around 10% were eventually referred for face to face consult. This signified high demand and acceptance for the service but – compared to the size of the Metro Manila population – capacity to provide the service was still not enough. Further scaling up the service entails cost in terms of training capable physicians and ensuring enough equipment.

To further improve access to telemedicine, DOH needs to establish a conducive regulatory environment through responsive policy-making and active engagement of these providers. DOH has facilitated multi-agency policy formulation for the sandbox, developed assessment mechanism to check on privacy as well as safety concerns of new health ICT, and engaged different telemedicine providers including the private sector. The DOH has also started to involve other agencies, like the Department of Interior and Local Government (DILG), in designing future enhancements as they continue to discuss the program to improve its implementation, especially in terms of adapting it to a devolved setting.

The sandbox approach has generated useful insights into the continuing and often unforeseen risks of telemedicine practice. Enabling policies to ensure patient safety and quality of service through teleconsultations comparable to that of face-to-face consults have yet to be fully developed. Another risk observed was the continued practice of offshore data processing and its implications on security and patient privacy. Ensuring access to technology in resource poor areas in the Philippines remains a concern.  Ultimately, the inadequate capacity of the government to regulate telemedicine, whether in terms of its legal framework, the skill of its regulators, or its resources to assess and engage providers, will serve as  a constant barrier if appropriate investments are not made.

The sandbox approach will help set a course for a stronger health system incorporating telemedicine in the post COVID world.  Gaining insight into the broader health policy environment within these controlled set-ups allows for the development of more dynamic and responsive policies that better fit the contexts unique to the country and the technology being regulated. With the continuing development in terms of access of the majority of the population to technology, the country can consider a phased approach to ensure that quality and equitable access is reached.