REVIEW OF TELEMEDICINE BUSINESS MODELS IN VIETNAM: FINDINGS, CHALLENGES, AND RECOMMENDATIONS DISCUSSION PAPER APRIL 2024 Lung Vu Sang Minh Le Ha Thai Vu Review of Telemedicine Business Models in Viet Nam: Findings, Challenges, and Recommendations Lung Vu, Sang Minh Le, and Ha Thai Vu April 2024 Health, Nutrition and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations, or to members of its Board of Executive Directors or to the countries they represent. Citation and the use of the material presented in this series should take into account this provisional character. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. For information regarding the HNP Discussion Paper Series, please contact the Editor, Jung-Hwan Choi at jchoi@worldbank.org or Erika Yanick at eyanick@worldbank.org. Rights and Permissions The material in this work is subject to copyright. Because the World Bank encourages the dissemination of its knowledge, this work may be reproduced, in whole or in part, for noncommercial purposes as long as full attribution to this work is given. Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. © 2024 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW, Washington, DC 20433. All rights reserved. ii Review of Telemedicine Business Models in Viet Nam: Findings, Challenges, and Recommendations Lung Vua, Sang Minh Leb, and Ha Thai Vuc a Health, Nutrition, and Population Global Practice, The World Bank, 1818 H Street, NW, Washington, DC 20043, USA. b Health, Nutrition, and Population Global Practice, The World Bank, 63 P. Lý Thái Tổ, Hoàn Kiếm, Hà Nội, Viet Nam. C Consultant, eDoctor, 69D Dinh Bo Linh, Binh Thanh, Ho Chi Minh City, Viet Nam. Abstract: This review was conducted using secondary data combined with key informant interviews aiming to (1) understand the current state of telemedicine services in Viet Nam, their business models and challenges; and (2) provide recommendations to guide national-level policy makers on how to strengthen telemedicine services in Viet Nam. Over the past five years, Viet Nam has seen a moderate growth in the number of telemedicine services, revenues, service offerings, and patient volume. Furthermore, these services’ functionalities can be grouped in three major types: (1) providing access to a second opinion on imaging and diagnostic tests, especially for providers working at commune or district hospitals (disadvantaged/ lower level of care); (2) using teleconsultations to screen and triage patients, then move a small proportion of patients who need in-person visits to offline facilities; and (3) enabling digital provider-to provider consultations on certain disease conditions or diagnostics. The authors recommends the government of Viet Nam to urgently establish a regulatory framework to keep up with the rapid development of telemedicine services in the country, which includes clinical guidelines for telemedicine practices for ensuring quality of care and protecting health workers and patients. Keywords: telemedicine, telehealth, business models, Osterwalder, Viet Nam Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Lung Vu @ lvu8@worldbank.org Table of Contents Abbreviations ii Acknowledgments iii Executive summary iv CHAPTER 1: INTRODUCTION 1.1 Background and context 1 1.2 Review methodology 4 CHAPTER 2: TELEMEDICINE BUSINESS MODELS 2.1 Overview of telemedicine providers in Viet Nam 6 2.2 Docosan 7 2.3 Doctor Anywhere 9 2.4 Doctor for Everyone 11 2.5 eDoctor 13 2.6 Hellobacsi 15 2.7 Hanoi Medical University’s Telehealth Program 17 2.8 Jio Health 19 2.9 Medon (Medlatec Group) 21 2.10 VietRadiology 23 2.11 VOVdoctor24 25 CHAPTER 3: DISCUSSION OF KEY FINDINGS 27 CHAPTER 4: CONCLUSION AND RECOMMENDATIONS 30 ANNEX 1: TELEMEDICINE SERVICES IN VIETNAM 32 ANNEX 2: REFERENCE 33 i Abbreviations CHS Commune Health Station DOH Department of Health ERP Enterprise Resource Planning GDP Gross Domestic Product HMU Hanoi Medical University IFC International Finance Corporation IT Information Technology LMICs Lower- and Middle-Income Countries MIC Ministry of Information and Communication MOH Ministry of Health NCD Noncommunicable Disease ODA Official Development Assistance OOP Out-of-Pocket PACS Picture Archive and Communications System PHC Primary Health Care SAP Systems Applications and Products UHC Universal Health Coverage UNDP United Nations Development Programme VSS Viet Nam Social Security VOV Voice of Viet Nam WB World Bank WHO World Health Organization ii Acknowledgments This discussion paper was prepared under the overall guidance of Christophe Lemiere (HD Practice Leader, World Bank), Aparnaa Somanathan (HNP Practice Manager, World Bank), Ronald Mutasa (HNP Practice Manager, World Bank) and Carolyn Turk (Viet Nam Country Director, World Bank). The authors are grateful to the peer reviewer Ali Habib (Digital Health Specialist, World Bank) for his constructive comments on an earlier version of the report. The team would also like to thank Nga Thi Anh Hoang (Program Assistant) for her excellent administrative support throughout the report preparation. Special thanks to the Viet Nam Ministry of Health, telemedicine providers, and development partners who participated in consultative workshops and meetings. The team acknowledges the funding from the Access Accelerate Initiative (AAI) and Japan Policy and Human Resource Development Fund (PHRD). Finally, this paper would not have been possible without insights from the managers and/ or founders of the 10 telemedicine businesses selected for the review. iii EXECUTIVE SUMMARY Despite telemedicine’s demonstrated positive impacts around the world for several decades, Viet Nam has yet to capture the full potential of this modality in bringing care to patients and filling several critical health care gaps such as lack of care options, unequal distribution of qualified health care workers, and unequal access. To date, the country only has a handful of telemedicine services, of which most are privately owned and technology start-ups. There is limited information on who the clients are of these services; whether these services are affordable and reach the populations in need; what is the perceived quality; what is its business model and whether it is profitable; and the challenges and bottlenecks that have been holding back telemedicine services growth, sustainability, and maturity. The authors conducted this rapid review using secondary data combined with key informant interviews with two key objectives aiming to (1) understand the status of telemedicine services in Viet Nam and their business models and challenges, and (2) provide recommendations to guide national-level policy makers on how to expand and strengthen telemedicine services in Viet Nam. Over the past five years, Viet Nam has seen considerable growth in the number of telemedicine services, revenues, service offerings, and patient volume. Furthermore, telemedicine services can be categorized under three major models: (1) providing access to a second opinion on imaging and diagnostic tests, especially for providers working at commune or district hospitals (disadvantaged/lower level); (2) using teleconsultations to screen and triage patients, then move a small proportion of patients who need in-person visits to an offline facility, and (3) enabling digital provider-to provider consultations on certain disease conditions or diagnostics (often difficult cases or cases that need expert opinions). The review also sheds light on several key challenges, which are major obstacles to the development and sustainability of telemedicine in Viet Nam. These include the lack of a legal framework, guidelines on payers and insurance reimbursement, liability, and clinical protocols and standards for telemedicine practice. Furthermore, many Vietnamese are still new to this model of care and therefore hesitant to use it. Based on the key findings, we make the following recommendations: 1. Establish a regulatory framework. Telemedicine is evolving rapidly, and a regulatory framework must be established to keep up with its fast-paced development. Developments of clinical guidelines for telemedicine practices to ensure quality of care and to protect health care providers and patients are urgently needed. These guidelines should also provide details on procedures for obtaining consent, ensuring health care providers are registered medical practitioners, and prescription management via telemedicine. It is critical to emphasize that such clinical protocols must be evidence-based and properly adapted to telemedicine and easy to implement. 2. Regularly use data to understand users’ insights and customer segmentations as a way to improve equitable access and to address the gender and rights aspects. If the telemedicine service is meant to increase health care access to those in need, careful consideration of the Internet connectivity is critical. In addition, pay special attention to the needs of disadvantaged groups, including people with low literacy or few digital literacy skills, people with limited control over or access to digital devices, people speaking minority languages, and people with disabilities. iv 3. Telemedicine should be able to integrate and exchange data with other digital systems to ensure continuity of care and accountability. These may include electronic medical records and laboratory information systems. It is also critical to ensure data security and that patients are made aware of and consent to a recording of their telemedicine consultation. 4. As a new model of care, process and outcome evaluation of telemedicine services in Viet Nam will be needed. Evaluation findings can help generate evidence to guide policies and improve the telemedicine practice. v CHAPTER 1: INTRODUCTION 1. Background and context 1.1 Overview of telemedicine. For more than several decades under the advancements of internet, telecommunications, and computer capacity, health providers have been using information technologies to improve health care [1-7]. One of these efforts is telemedicine— defined by the World Health Organization (WHO) as “The delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment, and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities”[1]The WHO further categorizes telemedicine as a component of telehealth, which is a broader application of technologies to distance education and other applications wherein electronic communications and information technologies are used to support health care services [1]. In its Guideline: Recommendations on Digital Interventions for Health System Strengthening, the WHO recommends telemedicine in circumstances where it complements, rather than replaces, face-to- face delivery of health services; and in settings where patient safety, privacy, traceability, accountability, and security can be monitored [2, 5] Telemedicine can also be understood as a set of diverse applications and may be conducted between clients or patients and health providers or among different health providers [2]. These include long-history uses of the telephone for consultations between patients and clinicians and the use of radio to link emergency medical personnel to medical centers. Most recently, telemedicine includes innovations such as telesurgery in which a surgeon receives visual information to guide robotic instruments to perform surgery at a distant location. More commonly, especially as the result of the COVID-19 pandemic, an array of video, audio, and data transmission technologies and applications such as videoconferencing have been used [8-10]. In these interactive videoconferencing sessions, clinicians can see, hear, examine, question, and advise distant patients for "real-time" diagnostics and treatment. Additionally, there are technologies that save and transmit digital images and other information to doctors or technicians who can receive and interpret them at their convenience, thus offering health providers more scheduling flexibility. In addition to providing patient-provider communication, telemedicine can be used for tele-assistance when a care provider needs advice from another provider or expert. This provider-to-provider channel allows consultation with one or more professional from the same institution or different institutions, or even different countries. The most common limitations and barriers for health care providers to use telemedicine include the lack of a regulatory framework, legal concerns, reimbursement and payer issues, and heath records and data security issues. There are also situations in which an in-person medical exam is required. These include mandatory exams for first-time patients (most critical diseases), or for specific conditions (old age, chronic disease condition, lack of mobility). Other barriers to consider include technology use among older adults; limited internet bandwidth in rural or underserved areas; and unclear guidance on practice standards, protocols, and supervision requirements, among other liability issues. A silver lining is that the COVID-19 pandemic accelerated the implementation of telemedicine and showed that, besides the crucial benefits of reducing contamination, many of these limitations can be overcome. In addition, in many countries, health insurance and medical organizations found ways to address the legal and payment issues, and patients showed high willingness to use digital tools and telemedicine. 1 1.2 Progress and challenges in the health care sector of Viet Nam. Viet Nam has made remarkable progress in economic development, poverty reduction, and key health outcomes for its people over the past several decades. Between 2002 and 2022, gross domestic product (GDP) per capita increased almost 10 times, from US$431 to over US$4,162 in 2022 [11]. Poverty rates have declined sharply from nearly 60 percent in 1993 to below 5 percent currently. The under- five mortality rate fell from 51 to 21 per 1,000 live births between 1990 and 2021. Viet Nam’s Human Capital Index increased from 0.66 to 0.69 between 2010 and 2020, exceeding global and regional level for lower-middle-income countries [11]. However, many challenges in the health system remain including access to care, quality of care, and the overall experience of care. In general, there is a shortage of trained physicians and hospital beds. Viet Nam has 2.6 beds and 0.8 physicians per 1,000 population [12] (by 2022), which is significantly less than the WHO-recommended minimum of 2.9 beds and 1.5 physicians per 1,000 population [12]. To make this problem worse, most Viet Namese doctors prefer to live and work in big cities and large urban settings or work at central hospitals, resulting in inequality in health access, especially access to qualified doctors [13]. With nearly 70 percent of Viet Namese living in rural areas, the unequal distribution of doctors forces people to travel long distance to seek care, causing many pain points along their care journey such as long wait time, high cost of travels, high out-of-pocket payments (because insurance don’t pay for people who seek care at an unassigned care level), and many have died unnecessarily on their way to seek care at central hospitals. Because many primary care hospitals (commune and district levels) lack high-ranked, experienced doctors, they often don’t have enough patients. On the contrary, demand to seek care at central hospitals often exceeds its capacity [14]. How to attract doctors to remote and rural areas, or at the least, how to exchange and transfer knowledge from doctors working at central hospitals to doctors at the primary care levels has been part of the government’s efforts. These efforts include improving the quality of human resources and quality of medical training and providing incentives to retain doctors at the primary care level, reducing the rate of unnecessary patients referred from lower-level to higher-level hospitals, and reducing overcrowding in upper-level hospitals. The government of Viet Nam (GoV) especially recognizes telemedicine and telehealth consultations as a mean of improving health service quality, reducing health care shortage in remote areas, and facilitating medical training and decision-making of health care professionals in remote areas [15]. 1.4 Telemedicine potential for Viet Nam. As noted above, telemedicine enables health care professionals to evaluate, diagnose and treat patients remotely using telecommunications technologies. A well-designed telemedicine model can bridge health care disparities, reduce cost of care, and improve quality of health care [16]. For example, for underserved populations or individuals who otherwise face high burden of travel times and cost to receive specialty care, patients who are too sick/or are unfit to be transported or suffer from chronic conditions as well as for people who are busy balancing multiple responsibilities between family, work, and life, the convenience of telehealth offers suitable options and better facilitates continuity of care. This indeed aligns with GoV’s efforts to provide equal access to quality medical services to everyone. Teleconsultation (telemedicine) has been in Viet Nam for over two decades. Since the 2000s, several hospitals have adopted telemedicine to provide remote training and consultations but encountered numerous challenges in mainstreaming it into routine operations. The COVID- 19 pandemic, while causing serious health service disruptions, has been a key driver for scaling up teleconsultation in the hospital network. In June 2020, the Ministry of Health (MOH) launched the “Remote health care” project, which supports provider-to-provider teleconsultation between health facilities at various levels. By the end of 2021, the remote health care project had expanded to 1,500 health care facilities from the central down to the provincial and district levels, involving 4,000 health professionals at the central level and 15,000 health professionals at the lower levels. 2 Telemedicine services have grown especially fast in the private sector as well as during the COVID-19 pandemic (2020–2022). Notable examples of telemedicine businesses include Doctor Anywhere, Docosan, eDoctor, Jio Health, and MedOn, which offer online booking, video consultations, referrals services, home care, and home delivery of medicines to their clients. These providers have also seen remarkable growth in the number of users, particularly thanks to the abundant use of smartphones and excellent internet coverage [17] 1.5. Objectives of the review. Despite telemedicine’s demonstrated positive impacts around the world for several decades, Viet Nam has yet to capture the full potential of telemedicine in bringing care to patients and filling several critical health care gaps discussed above . To date, the country only has a handful of telemedicine services, of which most are privately owned or technology start-ups [17]. There is limited information on the clients of these services, whether these services are affordable and reach the populations in need, its quality, its business model and whether it is profitable, and the challenges and bottlenecks that have been holding back telemedicine services’ growth and maturity. Prompted by these questions, the World Bank team conducted this rapid review with two key objectives. First, we aim to understand the status of telemedicine services in Viet Nam, their business models, the challenges they face, and their wishes to fulfill their mission of jointly improving health care services for Viet Namese people and sustaining and achieving scale. Second, we aim to provide recommendations to guide national-level policy makers to encourage and strengthen telemedicine services by stimulating infrastructure development, funding specific telemedicine programs, having a clear regulatory framework, and reducing policy barriers. The second objective is critical because many telemedicine services grew too quickly in response to emergencies caused by the COVID-19 pandemic, while guidelines and regulations have not been able to catch up. To successfully reap the benefits of telemedicine, proper guidelines and planning, and operating processes are required. 3 2. Review methodology 2.1 Listing of telemedicine businesses. We started by speaking to an experienced chief executive officer (CEO) of a successful telemedicine start-up who had good knowledge of the network of telemedicine service providers currently operating in the Viet Nam health care market. From this conversation, we completed a list of 30 telemedicine businesses (see Annex 1). We complemented this list with an open search on Google using key words to gather additional information about these businesses. We then explored each telemedicine service by reading key information on its websites. Ten service providers were chosen for the review. Since there were only three public sector or donor-funded telemedicine services, we selected all of them. For private sector telemedicine services, we purposely selected seven companies representing different types of business models currently operating in the Viet Nam market, including the number of years of operations (at least three years), their service offerings, and the types of technology interfaces used—teleradiology, video consultations, phone consultations, and telemedical education. We would like to note that the review does not include an exhaustive list of all telemedicine businesses in Viet Nam. 2.2 Semi-structured interviews. The review was based on available secondary information (reports, websites, articles), supplemented by semi-structured face-to-face interviews with the head or management team (key informants) of the chosen businesses. Each interview lasted for about an hour. Semi-structured interview is a suitable choice for the exploratory nature of this review. Key informants were asked to verbally consent, and all were informed that they could refuse to answer any questions deemed sensitive. We chose Alexander Osterwalder’s ‘‘Business Model Canvas” [18] as the basis for describing the telemedicine business models because it covers client-facing aspects such as value and affordability, as well as its cost structure and revenue streams, which are vital for business start-ups. This chosen business model canvas has nine domains, covering three main areas of a business: desirability (values, customer segments, customer relationships, channels); viability (revenue, cost); and feasibility (key resources, key activities, key partners), illustrated in Table 1. 4 Table 1: Alexander Osterwalder’s ‘‘Business Model Canvas” Domains Description These are activities that the venture needs to undertake to deliver the value Key activities proposition to the customer. Value is provided by the telemedicine system to the customer and the consumer. This encompasses economic value as well as social value. What Value keeps the customer coming back? The value proposition is the main focus proposition of the ‘‘Business Canvas’’ and is especially important in highly personal health care industries such as telemedicine. Customers are the individuals or organizations paying for the telemedicine service. The customer paying is not necessarily the same as the consumer Customer who uses the service. Although one entity may purchase the service, the segments benefit of the service may reach beyond the customer to a separate consumer. The primary interface is between the provider and the customers, where Channels value is delivered. All of the telemedicine ventures discussed in this article utilize either the internet, the telephone infrastructure, or both. Revenue These are sources of income generation. streams Key These are important technology, infrastructure, or human resources that resources sustain the venture and are essential for delivering the value proposition. Key These are normalized relationships with other entities besides the customer partnerships to create, deliver, and capture the value. Types of relationships are maintained with customers directly and indirectly. Customer How is a positive relationship generated between the provider and the relationships customer? Cost This involves the costs of all business operations for the venture. structure 5 CHAPTER 2: TELEMEDICINE BUSINESS MODELS 2.1 Overview of selected telemedicine providers This chapter describes the key review findings of each of the 10 selected telemedicine providers. For each provider, we provide (1) key administrative figures; (2) an overview of how it was founded, its business model, successes, and challenges; and (3) a table that summarizes the nine business model domains (listed in alphabetical order). https://worldbankgroup.zoom.us/s/92447093086Table 2 below summarizes key telemedicine services that selected models are delivering. We noted that a business model often expands its services beyond telemedicine to optimize its resources. Table 2: Type of telemedicine services (by alphabetical order) 6 2.2 Docosan Year started 2020 Location Ho Chi Minh City Managing agency Docosan Co. Ltd Website https://www.docosan.com Client volume Average 400–500 clients per day Overview Docosan was founded in 2020 and is a health care marketplace in Viet Nam, where patients can find and book medical appointments. Its mission is to allow patients to access affordable and quality health care services easily and conveniently, ultimately generating impact. Users can also manage and access their medical records and receive personalized health information and health education through the website. Docosan is the only telemedicine business with a female CEO/founder who is passionate about caring about the health and well-being of women, the underserved, and vulnerable populations. Docosan focuses on providing reproductive health and human immunodeficiency virus (HIV) and sexually transmitted infection (STI) testing services. Clients can compare health care providers across 29 medical specialties, view pricing information, read reviews, book appointments online 24/7, and chat with primary care assistants. The platform is also used by providers to manage bookings, offer promotions, and send compliant health education and treatment reminder messages to patients. Docosan’s search bar enables search by location, allowing customers in need of emergency care to locate and book the nearest available services. Starting June 2021, Docosan offered teleconsultations, home delivery of self- test kits such as HIV and STI self-tests and pregnancy tests, and home delivery of pharmacies through partnering pharmacists such as the Long Chau pharma chain. Affordability, equity, and impact are the focus of Docosan. The private providers listed on Docosan’s marketplace also offer price transparency, such that actual or predicted price ranges are displayed. The current clients are largely from medium or large urban areas and cities. The company's goal is to grow the market to people in rural areas who are truly in need of telemedicine services. Key results of the business model analysis are presented in Table 3. 7 Table 3: Business model analysis Domains Description • Online health care marketplace for providers and clients Key activities • Online appointment booking and teleconsultations • A large range of health care services, especially reproductive health services • Expanded access to affordable health care services for women and the most Value vulnerable and stigmatized populations proposition • Increased patient experience and satisfaction in primary health care • Increased jobs and income for doctors • The largest number of clients are from Ho Chi Minh City, although the system has reached people in 24 provinces, mainly in the North and the South. A Customer customer segment that Docosan targets is women and men in need of sexual segment and reproductive health services including stigmatized and vulnerable populations. Equity and affordability are the goals of the company. It is believed it has reached an economically diverse set of clients. • Building a good and reliable platform (currently has a five-star rating) • Allows for patient’s feedback. To assist patients in making reviews of service Customer providers, Docosan provides tags such as “Attentive receptionist,” “Very relationships professional doctor,” and “Reasonable examination costs” among many others. Such tags allow patients to provide fast, valuable feedback without hassle and lead to increased utilization of this feature. • Providers: Docosan promotes all kinds of providers (young, experienced, general, specialist, etc.) with different price points, and allows patients to Key choose and rate their care providers. resources • Donors/investors. The company is still looking for investors. • IT is managed in-house through hired IT staff. • Dedicated team of staff • In-house IT team Key partners • Investors • Blog/content writers • Blogs and content-driven (currently it has about 32,000 blogs and content Channels pieces) • Marketing campaigns, chat on the website/24 hours, social media Cost • Most expenses are operational (staff, IT, offices) structure • The company is lean, and the focus is on social impact • Serve as a health care marketplace for providers and clients • Offer a large range of health care services, especially reproductive health Revenue services streams • Provide booking and medical teleconsultations • Link people with neighborhood drugstores IT = Information technology. 8 2.3 Doctor Anywhere Year started 2019 Locations Ho Chi Minh City and Danang, nationwide outreach Managing agency ClinPharm Website https://doctoranywhere.vn Client volume 20,000 clients Overview Founded in 2019 as a technology start-up, Doctor Anywhere (DA) aims to help clients access a large pool of health care options while removing or reducing the waste time and poor experience of having to navigate the traditional facility-based visit. DA offers telemedicine services, in-person visits at its clinics or participating clinics, home visits for medical consultations, laboratory testing and home specimen collection, and e-pharmacies. DA has 90 full-time staff and a network of nearly 400 contracting health care providers and pharmacies in major cities. The company is currently building several facility-based clinics and pharmacies to complement the telemedicine offerings, connecting patients whose in-person visits are needed. The company is considered as one of a few health tech start-ups that was able to raise a large amount of capital, totaling about US$140 million after three years. On average, Doctor Anywhere receives 300–400 bookings per day. All medical records are stored on the app for easy monitoring and future access. Patients can choose to share their medical records with their doctors. All patients can rate their visit experience and review their doctors after each visit. DA strives to keep services as affordable as possible. It is currently considered as having the most competitive pricing structure among the current telemedicine start-ups (with a fee of 100,000 [~US$4] VND per consultation session). DA also has relationships with a large number of private insurance companies and takes care of billing and insurance claims on behalf of patients. In addition, DA provides free information on its website, and health seminars virtually or in-person to maintain customer relationships as well to gain more new clients. Clients also have options to buy a 3-month, 6-month, or 12-month subscription and can access DA at any time during that period. Key results of the business model analysis are presented in Table 4. 9 Table 4: Business model analysis Domains Description • Online appointment booking Key • Provider-to-client teleconsultations via videoconference activities • E-prescription refills, medicine delivery • Medical records monitoring • Expanded access to PHC services Value • Improved patient experience and satisfaction proposition • Increased efficiency in operations • Patients are mostly working age who have good income and are able to pay Customer for services, either out-of-pocket or by a private health insurance. They mostly segment reside in large cities where JIO Health has offices and clinics (Ho Chi Minh City, Da Nang). • Use social media platforms to engage with clients Customer • Enable clients to rate or provide feedback to providers after an appointment relationships • Hold free health consultation events to engage with and keep clients up-to- date • Capital and network of DA offices in the region Key • Telemedicine platforms resources • 2 clinics and several pharmacies • 90 staff • Networks of partnering hospitals, laboratories, and pharmacies Key partners • 400 collaborating doctors • Insurance companies • Partner with employers and businesses (the key business model is Business- to-Business-to-Clients) Channels • Use apps, websites, social media platforms, and online medical content to stay in touch with clients as well as for commercial advertisement and promotion • Maintain quality and affordability to attract patients Cost • Start-up costs. DA’s mother company that supports IT and app development structure • Office and staff costs • 80% of revenues are from business demand, offering health care packages for Revenue employees. streams • 20% of revenues come directly from direct patient booking. PHC = Primary health care; IT = Information technology. 10 2.4 Doctor for Everyone Year started August 2020 8 provinces including Hà Giang, Bắcc Kạn, Lạng Sơn, Thừa thiên - Locations Huế, Bình Định, Cà Mau, Đăk Lăk, Quảng Ngãi Ministry of Health, provincial Departments of Health, United Nations Managing agencies Development Programme (UNDP) Commune and district health workers and higher-level experts; Client volume Limited number of patients (about 2,000 consultations between July 2021 to June 2022) Overview Doctor for Everyone is an UNDP-funded pilot project started in 2020 during the heightened period of the COVID-19 pandemic. The project goals are to (1) improve access to basic health services while under COVID-19 social distancing restrictions for ethnic minority population groups living in remote and mountainous areas, and (2) strengthen the capacity of grassroots-level health care workers. Ultimately, it aims to reduce the burden on high-demand health care facilities by providing providers at the commune and district levels with medical expertise and collective consultations to triage patients as well as diagnose and treat cases remotely. The pilot was implemented in three provinces: Hà Giang, Băc Kạn, and Lạng Sơn. The project goals are aligned with the “leaving no one behind” policy introduced by the GoV in 2020. Start-up activities included providing two servers to support the Data Center (housed at the MOH), and building and deploying the telemedical consultation app named “Doctor for Everyone.” Doctor for Everyone offers telemedical consultations between commune-level health providers and districts and provincial doctors/specialized doctors/experts through video calls. In addition, community health workers were trained to use portable telemedicine kits to connect with doctors and health care professionals remotely. These kits include medical devices such as digital stethoscopes, otoscopes, and cameras to enable doctors to remotely examine patients and provide medical advice. During the early phase, due to the lack of IT support, the app had several notable limitations, including (1) no separate account for patients to use (only providers can use the account); (2) no features to notify about missed calls or missed messages; (3) no features to remind users of the meeting time; (4) patients’ data are not stored; and (5) disconnection with major medical software such as health insurance payment, patient medical record system, and hospital management. By the end of Phase 2 (June 30, 2022), about one-third of trained health care workers used the app (30.4 percent) although 77 percent of health care workers in project areas were trained on using the app. A total of 1,012 apps were downloaded and installed. By June 2022, there were about 2,000 consultation calls recorded by the system. The end of Phase 2 evaluation documented several positive impacts of the project, including (1) enhancing people’s access to health services, (2) strengthening professional capacity for grassroots health care 11 providers, (3) strengthening the connection and sharing of information between medical facilities between levels in the local health network, and (4) reducing patients’ loads and waiting time at health facilities. Key results of the business model analysis are presented in Table 5. Table 5: Business model analysis Domains Description Doctor for Everyone focuses on strengthening capacity of grassroots-level Key activities health workers and improving access and quality of PHC services to the underserved/difficult-to-reach areas. The project ensures PHC services for people in need during the COVID-19 pandemic. It also aims to reduce the health care shortage by providing lower- Value level health care workers an opportunity to consult higher-level doctors through proposition video calls instead of sending patients to districts and provincial hospitals. Ultimately, patients can access better health services. It also saves providers and patients time and travel costs. All services are provided free of charge. Doctor for Everyone aims to reach people who are less likely to seek health Customer care due to limited access, lack of income, and long distant travel to health segment facilities. Mass media campaigns were conducted to raise awareness about the app and Channels encourage providers to install the app. The project was led by the MoH (MSA, IT Department) with technical Customer assistance from UNDP. Key partners included app builders, donors relationships (government of Japan and UNDP), provincial and district health departments, and selected/piloted commune health stations. Using existing health structures to maintain sustainability and expansion after Key the pilot phase. Limited capital was provided by donors during the pilot phase. resources The project provided a set of computer, audio, and video equipment to commune health centers in the piloted area. Demand creation was included as part of the project implementation using social Key partners media and mass media (health education events, oral communications from doctors to patients, interpersonal communications). Cost Not applicable. IT support was provided by the Department of Information and structure Technology at MOH. Seed funding was provided by UNDP. No revenue because the service was Revenue free to all users. The project is seeking additional funding to improve the app streams and to expand its coverage. IT = Informational technology; MOH = Ministry of Health; MSA = Medical Service Administration; PHC = Primary health care; UNDP = United Nations Development Programme. 12 2.5 eDoctor Year started 2014 Locations Ho Chi Minh City, Ha Noi, Can Tho, nationwide outreach Managing agency eDoctor SJC Website https://edoctor.io Client volume 400,000 clients per year Overview eDoctor was established in 2014 as a start-up with the mission of educating patients to understand their health, and to offer health services to help patients take control of their health. Following a hybrid model (online and in-person consultations), eDoctor aims to help providers reach patients and to help patients find a network of quality health care providers (hospitals, doctors, laboratories) through virtual clinics (a mobile application). This eDoctor app enables patients to connect with licensed doctors and health care professionals remotely, using video consultations or chat. Patients can use the app to schedule appointments, receive medical advice, and get prescriptions or referrals as needed. Services offered by eDoctor include the following: • A health care marketplace for providers, private insurance, and patients • Virtual appointments • Teleconsultations (chat, video calls) • Online account that can store patients’ medical records • Specimen collection at home • Delivery of diagnostic test results in near real time (directly entered an online platform by the laboratories) Participating providers are vested through doctors’ profiles, reputations, and patients’ reviews. All of these providers have to sign a contract with eDoctors and go through the mandatory onboarding procedure. By March 2023, there have been 600 individual participating providers/doctors with flexible hours (besides the standard 9–5). Payments come to participating providers directly through a virtual wallet minus the administration fee charged by the edoctor. In addition, eDoctor has a network of 100 participating clinics that offer clients laboratory services and health check-ups. Key results of the business model analysis are presented in Table 6. 13 Table 6: Business model analysis Domains Description Key activities • Serve as a marketplace for doctors, patients, laboratories, private insurance companies • Online appointment booking and provider-to-client teleconsultation • Health education sessions via chats, phone hotline, emails, events Value • Expanded access to PHC services proposition • Improved patient experience and satisfaction with PHC services • Increased jobs and incomes for health providers Customer • Most patients are in the 35–45 age range, residing in large cities (Ho Chi segment Minh City, Hanoi, Can Tho), and of middle- or high-income class. Customer • eDoctor maintains relationships with clients via free health education events, relationships virtual chats, fan pages, social media platforms, and users’ apps. eDoctor also conducts spot checks with patients to get patients' feedback to ensure quality of service. Negative feedback will be handled to ensure client satisfaction. • A list of clients is maintained for active engagement and reengagement. Key resources • A marketplace platform • 30 staff including a team of IT experts • 500 contracted nurses to collect specimens at home Key partners • More than 600 collaborating doctors, more than 50 collaborating clinics, and about 50 collaborating pharmacies • Several large private insurers (Cathay, Bao Minh) Channels • Website and app to conduct telehealth sessions • Advertise through social media including Facebook, Google, YouTube • Provide health education sessions free to people • Direct sales led by the sales team (20 staff) Cost structure • Start-up cost provided by investors • Permanent employees, including HR, managers, IT experts, sales/marketing, customer care • Building and maintaining the IT platforms (mobile app, website, software, hardware) incurs the major cost (currently estimated at 30% of the total service cost) • Providers/partners • IT infrastructure and technology exchanges • Marketing and sale costs Revenue • Home-based testing and health checkup services are the major sources of streams income • Revenue from service providers, health professionals PHC = Primary health care; IT = Information technology; HR = Human resources. 14 2.6 HelloBacsi Hello Health Group is present in 8 countries, established in Viet Nam in Year started 2015. Locations Ho Chi Minh City. Managing agency Hello Health Group. Website https://hellobacsi.com Client volume 12 million unique monthly visitors to its websites Overview HelloBacsi is a digital health ecosystem based in Viet Nam that provides free online medical information and health care services to the wider Viet Namese population, and since 2022 has also provided online consultations and health care professional appointment bookings. The company was founded in 2015 with the mission of making health care more accessible and affordable for Viet Namese people. Since its launch, HelloBacsi has grown to become one of the largest online health care providers in Viet Nam, with a library of more than 20,000 pieces of content, and a network of over 2,000 doctors and health care professionals serving millions of patients across the country. Notably, the company has the largest number of viewers per month in Viet Nam (with about 12 million visitors per month), and most of the revenue comes from business-to-business services and advertising. HelloBacsi's offerings include medically reviewed content, health tools, risk screeners, and knowledge-sharing via online communities moderated by the HelloBacsi AI. Users can also access online and offline medical consultations provided by health care professionals. The company recently launched a mobile app with telemedicine features and online consultation booking. The app includes HelloBacsi's industry-leading AI health care assistant, which answers users' questions instantly and recommends relevant next steps. As a digital health pioneer, HelloBacsi is the first to offer an AI assistant of this caliber in a health care app. HelloBacsi is the only platform in Viet Nam that has received the notable TRUST certification from AACI for the credibility of its medical content. In addition, HelloBacsi has been recognized for its innovative approach to health care and has received several awards. These include the Association of Southeast Asian Countries (ASEAN) Information and Technology (ICT) Award for Best Start-Up in 2016 and the Viet Namese Talent Award for Creativity. The Viet Nam market is considered the most successful among the eight countries where the parent company, Hello Health Group, operates. Key results of the business model analysis are presented in Table 7. 15 Table 7: Business model analysis Domains Description ● Online health information sources ● Online marketplace for pharmacy partners Key activities ● Online appointment booking and teleconsultation with health care professionals ● Hello Health is building the leading digital health ecosystem in SEA to Value drive convenience, transparency, & cost-effectiveness proposition ● Expanded access to doctors and PHC services ● Increased jobs and incomes for doctors ● Users from all over the country (urban and rural) Customer ● Large number of users from urban settings where internet and technology segment are more advanced; young and middle-aged users are a major segment Customer ● Maintain user base by ensuring service quality and medically reviewed relationships health content ● Two websites providing health information, tools, and services https://hellobacsi.com and https://www.marrybaby.vn/ ● Mobile app for end-users ● Large capital and investment; large market presence across Southeast Key resources Asia ● Large number of content writers (20,000 content pieces in Viet Nam; >103,000 pieces in 8 countries); large number of staff (100 in Viet Nam) ● Thousands of private providers using the tool “Hellobacsipro” ● Diagnostic centers, hospitals & hospital chains, medical device and Key partners pharmaceutical companies, pharmacy chains, and eCommerce marketplaces ● Insurance companies ● Website for end-users Channels ● Mobile app for end-users ● Tool “Hellobacsipro” for doctors Cost structure ● Mostly operational costs including office and staff Revenue ● E-commerce, advertising streams ● The company is confident it will be profitable by the end of 2023 SEA = Southeast Asia; PHC = Primary health care. 16 2.7 Telehealth Program in Hanoi Medical University Year started 2020 Locations Headquartered in Hanoi, outreach to 200 districts nationwide Managing agency Hanoi Medical University (HMU) hospital Website http://benhviendaihocyhanoi.com/ About 10 requests per day for teleradiology; About 1–2 requests per day Annual clients for other kind of teleconsultations Overview In 2020, MOH initiated a telemedicine program, and HMU is one of the hospitals selected to pilot and expand telemedicine in the public sector. The objectives of this effort are to (1) support and transfer knowledge to lower-level hospitals through telehealth, (2) safely provide health services to patients and clients during the COVID-19 pandemic, (3) improve health care access to people living in remote and rural settings, and (4) reduce health care cost to patients by reducing the need of transferring patients from lower-level hospitals to central hospitals. Key activities as part of the government effort are establishing a telehealth unit with advanced information technology (IT) solutions; providing telehealth consultations to lower-level hospitals (mostly district hospitals); providing teleradiology consultations for lower-level public hospitals and some private hospitals and large clinics; providing teleconsultations for other key diagnostics tests such as blood tests, biological tests, and autopsy; providing teleconsultations for surgeries; and providing medical training remotely to lower-level doctors with the goal of knowledge transfer to improve health care quality and health care access for people living in remote and rural areas. As this is part of a government effort, no fee is collected from patients by public sector hospitals. A small fee is collected from users by companies that provide IT solutions. Between April 1, 2020 and January 31, 2021, approximately 120 doctors participated in the tele-remote learning sessions from HMU. In addition, 498 patients were tele-remotely consulted. Of those, only 93 cases were transferred to central hospitals. A key challenge is the lack of government guidelines, which prevents the hospital from collecting users’ fees or charging the insurance. Key results of the business model analysis are presented in Table 8. 17 Table 8: Business model analysis Domains Description Key activities • Teleconsultations between providers or with patients and providers (patients sit next to their doctors during the session) (at commune, district level) • Teleradiology • One pilot tele-ICU Value • Provide high-quality consultations to lower-level doctors proposition • Improve access to quality health care for people living in remote and rural settings, ensuring equity and fairness for all. Customer • 200 district hospitals and several private clinics have participated. Health segment facilities in rural and underserved areas express greater interest. Channels • Referral system in the public health care network and HMU hospital’s fan page Customer • HMU hospital signed memos to support participating hospitals. relationships Key • A telehealth center equipped with a telehealth system. 120 doctors participated resources in the telehealth program. 2 full-time staff assist with appointments and setting up meetings for doctors. Key partners • Viettel is the IT partner providing the IT solutions and some funding to equip the telehealth center. Cost • Start-up costs covered by IT companies. Staff times are paid by the hospital structure through regular compensation. Revenue • Most services are free. Some private hospitals and providers pay a small fee streams directly to doctors who provide telehealth consultations. ICU = Intensive care unit; HMU = Hanoi Medical University; IT = Information technology. 18 2.8 Jio Health First founded in 2011 (US-based start-up), established in Viet Nam in Year started 2014 Locations Hanoi and Ho Chi Minh City, nationwide outreach Managing agency Jio Health Clinic Website https://jiohealth.com Client volume 400–500 clients per day Overview Jio Health was launched in 2014 as a digital health start-up operating an online and offline health care ecosystem. Jio’s health mission is to provide clients with a menu of options for quality health services and allow clients to schedule health exams or medical appointments at a place and time of their choice, ultimately saving time and money and improving their service experience. On the system level, it aims to reduce unnecessary visits and wait times at health facilities. Jio Health’s technology encompasses telemedicine platforms, e-prescriptions, digital medical records, and machine learning for clinical decision support. Beyond virtual care, the offline network of Jio Health's ecosystem consists of smart clinics, on-demand home care, and an extensive and growing network of 300+ Jio-branded neighborhood pharmacies. Jio Health currently offers an extensive range of health services, including the following: • Online appointment booking, which links to offline services at one of Jio's health clinics at partner clinics or at home • Home-based specimen collection (for laboratory testing) • Home delivery of medicines using Jio’s partnered online pharmacies • Free health advice 24/7 via a hotline • Electronic medical records: patients have access to medical records at any time • Home-based nursing for simple procedures (such as wounds, sinus cleaning, and injections) The unique feature of Jio Health is its smart clinics (it currently has five clinics) with integration of the above features. Clients can also create a profile for themselves and family members. All patient records are completely confidential according to Health Insurance Portability and Accountability Act (HIPPA) guidelines as Jio Health was first established as a US-based start- up. Jio Health apps currently has about 300,000 active users. Key results of the business model analysis are presented in Table 9. 19 Table 9: Business model analysis Domains Description Key activities • Provider-to-client teleconsultations through 150 multispecialty care providers on its platform • Home-based care; offline services at Smart Clinics • e-prescriptions via its mobile app or website. Value proposition • Expanded access to PHC and specialized services • Improved patient experience and satisfaction. The uniqueness of Jio Health’s model is that it owns several smart clinics, giving clients full experience of Jio (and online to offline when necessary) • Increased efficiency in operations (screening and triaging) Customer segment • Most current Jio Health clients reside in urban Ho Chi Minh City, and can pay for premium services and membership, either by out- of-pocket or by private health insurance. Customer • Jio Health strives to keep clients by enhancing user experience and relationships care quality. It also offers free health education campaigns; online health education content, events, and a free hotline. Clients can rate and review their service providers after each visit. Doctors who receive low ratings will receive a warning and their contracts may be terminated. Key resources • US$20 million Series B investment • Telemedicine platform including e-prescription, electronic health record system, and machine learning for clinical decision support • 5 smart clinics and 300 Jio-branded neighborhood pharmacies • 60 full-time staff and 150 contracted multispecialty care providers Key partners • Investors • 300 Jio-branded neighborhood pharmacies • 150 multispecialty care providers Channels • Jio Health delivers its service to clients through a combination of an app, a website, a hotline, and clinic-based and home-based services. Teleconsultation aims to assess the patient’s condition, understand their needs, and determine whether the persons need to be referred to the clinic. Cost structure • The major cost element is for its staff and contracted medical providers • Investment and maintenance of telemedicine platform and smart clinics Revenue streams • The major source of income comes from selling medicines (60%) and health checkups for businesses and individuals (40%). PHC = Primary health care. 20 2.9 MedOn (Medlatec Group) Year started 2020 Locations Headquartered in Hanoi, nationwide outreach Managing agency MedOn JSC Co. belonging to Medlatec Group Website https://booking.medon.vn/; https://medlatec.vn/ 4,000–6,000 calls for telecounseling and 200–300 X-ray readings per Client volume day Overview Medlactec was founded in 1996 and is considered one of the largest and most mature health care providers in Viet Nam. It has a hospital, 42 clinics, 30 laboratory testing facilities and 200 laboratory sample collection points. It serves 2 million clients per year covering 50 provinces. Medlatic is one of the few pioneers that uses digital technologies for improving patient’s experience and quality of health service. In 2020, Medlatec established MedOn, a telemedicine/digital health. Medon digital structure includes SAP ERP, medical record system, laboratory management system, point of sales, and electronic payment. Medon helps patients manage their health and order laboratory tests (including the most common blood tests), chest X-rays, and different kinds of medical imaging diagnostic services. Patients can receive test results and consultation briefings within the same day. Through “mymedlactec” app, client can create their health profile, book appointments, and manage their health digitally. Client can access their health information at any time. They can also choose certain providers with whom to share their medical records. 21 Table 10: Business model analysis Domains Description Key • Telecounseling via a call center, a hotline, and virtual chat rooms activities • Online appointment booking and provider-to-client teleconsultations • Provider-to-provider teleconsultation, teleradiology, tele-ultrasound Value • Expanded access to outpatient and home-based services proposition • Improved patient experience and satisfaction • Enhanced quality of health care services • Increased efficiency in operations Customer • Most patients are living in urban settings and have good income and are willing segment to pay out-o-pocket or have private insurance. Channels • Medlatec uses website, hotline, app, and common social media platforms (Facebook, Instagram, YouTube), and a near-free health education hotline to reach and engage with patients. Customer • Patients can rate or provide feedback to providers after each appointment. relationships • The company also uses a point system and discount to encourage patients to come back. Key • Medlatec is considered one of the most successful private health care networks resources in Viet Nam and has revenue to invest in MedOn and its telemedicine arm. • Telemedicine platform and IT infrastructure as presented in Figure 8 • 30 IT specialists and 20 health counseling specialists • Health professionals in Medlatec (20 full time doctors; 30 part-time doctors; 253 partnering doctors; and 3,000 collaborating doctors) • Facilities (multiple clinics and 2 large hospitals) Key partners • FPT provides IT infrastructure/solutions • A network of pharmacies that patients can contact to buy medicines • Private insurance providers (30) • Academia/research institutes (national and international) Cost • Staff is the major cost element structure • Investment and maintenance of IT infrastructure: data servers, internet safety and security • Marketing, communications • Land acquisition to expand the network of clinics and facilities Revenue • Home-based care services are the major sources of income streams • Teleradiology, tele-ultrasound, and teleconsultations are being expanded and helping to increase revenue • Collaboration with private insurance companies selling insurance IT = Information technology. 22 2.10 VietRadiology Year started 2017 Locations Headquartered in Hanoi, office in Ho Chi Minh City, nationwide outreach Managing agency Minerva Website http://www.minerva-pacs.vn/ Annual clients 130 hospitals and clinics Overview VietRadiology was founded in 2017 as a technology start-up with the mission of offering technological innovations to imaging diagnostic providers/departments in Viet Nam. The company also aims to invest in research and development to continue improving its products, quality of the images, and accuracy of diagnostics, and reducing costs. The company currently offers three solutions: a. Telerad can transfer images live and is used in teleconsultations between doctors. This helps save costs for patients by not having to be transferred from one provider to another. This also helps doctors to seek expert opinions on their imaging diagnostic needs b. PACS (short for Picture Archiving and Communication Systems) is an app to store medical images with high quality. It serves as a primary communication bridge between radiologists, radiologic technologists, and referring providers. PACS enables all authorized clinicians to access medical images and reports quickly from virtually any location. Some health systems have integrated PACS into the electronic medical record (EMR). c. RIS: Integrated with PACS to give imaging departments and doctors instant access to all images and data created along the patient’s pathway. Vietrad solutions have reached 130 hospitals and clinics in Viet Nam with an estimated 60,000–80,000 cases per year. Most of the teleradiology consulting needs are from lower levels (provincial and district hospitals and private practices) to central hospitals. About 70 percent of the requests came from the public sector. This new technology has benefited both patients and doctors, reduced wait time, and lowered health care costs, and has transformed medical education from higher-level hospitals and imaging experts to doctors working at lower-level hospitals. Key challenges for Vietrad include lack of knowledge among many providers about the imaging teleradiology solutions, high start-up costs, and lack of regulatory guidelines on both practices and payment aspects. Key results of the business model analysis are presented in Table 11. 23 Table 11: Business model analysis Domains Description • Provide medical imaging solutions for teleradiology needs for medical Key activities imaging departments and doctors Value • Improved quality of care, reduced patient wait time proposition • Increased efficiency in operations Customer • 130 hospitals and clinics with 60,000–80,000 cases per year. About 70% segment of the cases came from lower-level hospitals and the public sector. Customer • Maintained by the quality, convenience, and ease of use of the product relationships • Teleradiology system, PACS, RIS Key resources • 40 full-time staff in the 4 following areas: research and development, product programming, solution intervention, and business finance • IT companies Viettel and FPT Key partners • Supplier of radiology technology GE • Hanoi University of Technology • The products are integrated with the IT system, both app and web-based Channels • The marketing department expands the products to more users Cost structure • Start-up’s client, office, and staff costs are the major cost elements. • Incomes come mainly from (1) providing solutions to clients, (2) a small Revenue fee for imaging transfers (about US$1 per case), and (3) teleradiology streams consultations between imaging doctors (about US$10 per case) IT = Information technology; PACS = Picture Archive and Communications System; RIS = Radiology Information System 24 2.11 VOVdoctor24 Year started 2017 Locations Headquartered in Hanoi, nationwide outreach Managing agencies VOV’s radio channel on health FM89mhz and a private operation entity Website https://vovbacsi24.com/ Client volume 41,100 active users Overview VOVbacsi24 was launched as a public sector telehealth provider aiming to reach people living in rural and remote settings. It received strong political support from Voice of Viet Nam (VOV) leadership as well as the MOH, the Ministry of Information and Communication (MIC), and many central and teaching hospitals. VOV partners with renowned doctors from well-known central hospitals around the country because it believes high-quality doctors will be able to offer quality services to clients. Offerings include telemedicine consultations for different types of specialties. VOVbacsi24 has reached clients across the country as well as Viet Namese living overseas. During COVID- 19, it provided services to about 200 clients per day through phone calls. About 30 percent of the calls were COVID-19–related. Starting in 2022, VOVbacsi24 developed and launched an app that allows patients to connect with and receive teleconsultations from highly qualified doctors. Providers set prices depending on specialty and their qualifications and experience. Doctors can also prescribe medications for patients after each telemedical consultation session. Patients can choose service providers and pay for services via e-wallets included in the app. Currently, VOVbacsi24 operates as a public-private mix. It hopes to expand the client base by continuing to modernize the consultation website and app, offering more services, and having more staff. The company said it is looking to raise capital to grow the business. 25 Table 12: Business model analysis Domains Description • Online appointment booking via website or mobile app Key • Provider-to-client teleconsultations via phone and videoconferencing activities • Telecounseling via phone • Fast and easy access to general, specialized, and reliable doctors in public Value hospitals via the website, phone, and mobile apps proposition • Access to health education and promotion via VOV’s radio channel on health FM 89mhz. • Viet Namese patients who want and can pay out-of-pocket for Customer teleconsultations; 30 percent of patients are from Ho Chi Minh City, the rest segment (a majority) are from other part of countries, especially the North. It also reaches Viet Namese living overseas and migrant workers. • Due to its famous name—VOV—the program is well known. This is the key Channels feature driving people to the program and its digital platform. • VOVdoctor24 signs contracts with hospitals for providing teleconsultation Customer services. Clients can rate providers after each service appointment. relationships Comments can be provided directly on the website. • VOV’s radio channel on health FM89mhz, which is a well-known and favorite channel for service delivery and marketing. Key • E-commerce marketplace including website and mobile apps to connect resources patients with doctors. • 40 full-time staff and nearly 2,000 contracted doctors. Leadership and support from VOV. Key partners • MOH and the MIC Central and provincial hospitals nationwide Cost • Investment, operation, and maintenance of the health care marketplace structure • Salary for staff Revenue • Mostly publicly funded from the government budget streams • A small portion of revenue from user fees for providers VOV = Voice of Viet Nam; MOH = Ministry of Health; MIC = Ministry of Information and Communication. 26 CHAPTER 3: DISCUSSIONS OF KEY FINDINGS This chapter summarizes and discusses the key review findings, both successes and challenges, aiming to inform policy recommendations on whether and how to best integrate telemedicine into the overall health care system and how to ensure the quality of telemedicine services. Telemedicine is predicted to grow at a faster rate post the COVID-19 pandemic (20 percent compared to 15 percent before COVID-19) and would help global economic recovery in a post pandemic world, with the potential to provide safe, efficient, and cost-saving health care to remote and underserved populations [9, 16, 19-21]. Our interviews with 10 business leaders and key informants have confirmed their positive views of telemedicine as a business and as an important player in strengthening the health care sector of Viet Nam. Although only two of the ten businesses are currently profitable, all are confident that they will likely be profitable or continue to grow and expand in the near future, especially when the government has clear protocols on telemedicine practices as well as reimbursement guidelines and a legal framework. One fascinating finding from the semi-structured interviews was that the founders of these start-ups or the lead of the public projects were all passionate about telemedicine as a tool to improve access and quality of health care for Viet Namese people. Some of them had backgrounds in public health; some were from the tech industry. Nevertheless, they were all deeply concerned about notable pain points that Viet Namese people have to go through to navigate the health care system, including inefficiency, long wait times, unequal access, and lack of care options. Regardless of their background, they do have the desire to make their business both profitable and more affordable to expand the customer segmentations and to generate social impact. Some services such as Docosan focus on impact and promoting health care access to the most vulnerable populations such as women, adolescent girls, and the lesbian, gay, bisexual, and transgender (LGBT) community. Another key finding is that all reviewed private telemedicine providers offer ease-of-use and top-notch IT functions/apps. Further, some businesses are willing to promote young doctors to diversify and strengthen health and human resources. Their general view is to let clients’ ratings and feedback mechanisms determine the demand for each participating doctor. Our review also found that, in Viet Nam, telemedicine offerings can be categorized under three major models: (1) providing access to a second opinion on imaging and diagnostic tests, especially for providers working at commune or district hospitals (disadvantaged/ lower level); (2) using teleconsultations to screen and triage patients, then move a small proportion of patients who need an in-person visit to an offline facility; and (3) enabling digital provider-to-provider consultations about certain patients (often difficult cases or cases that need expert opinions). Screening patients before they arrive at a clinic or emergency room improves efficiency and safety since prescreened patients generally spend less time waiting for care and providers. It has led to fast tracking non-severe patients, reduced wait times and virtual medical exams. For most businesses, their screening time was about just 10 minutes. They believed these 10 minutes can save patients a lot of time and downstream costs, and in many cases, can save lives. Seven of the ten businesses under review offered a broad spectrum of general health or specialized health care services through a large network of participating or contracting providers; some have their clinics as in the case of JioHealth or Doctor Anywhere. About half of the reviewed telemedicine providers also offered home-based care and home-based specimen collection. Although we were not able to interview clients who have used these telemedicine providers, overall ratings and reviews provided by patients on these companies’ websites are extremely positive, both before and after the pandemic (4.5 stars out of 5 stars). These findings are 27 consistent with findings from studies that show high satisfaction with telemedicine, including studies conducted in Viet Nam. These results indicate that in the long term, telemedicine will likely stay and play a significant role in providing primary care, especially for patients who prefer or need this format. One area that shows mixed findings is affordability and equity. Most of the private start- ups are driven by profit and due to the lack of guidelines on payers and insurance reimbursement, these providers focus on middle- and high-income clients who can pay by cash or by private insurance. As a result, these clients can receive higher-quality and convenient care through telemedicine; however, telemedicine may not fill in the gap in health care access nor whether it serves people who live in remote or rural areas. Nonetheless, our discussions with business leaders showed that they do understand these limitations and hope in the long term to expand and offer services at a more affordable or discounted price to poorer segments of the population. Some services are already quite affordable such as through Docosan, Doctor Anywhere, and Hellobacsi. The public sector telemedicine services are free to clients and providers, but one challenge they all face is funding and whether these projects can be sustained or integrated into the overall health care system. VOVbacis24, which has been transitioned from the public sector to a public-private mix can be a good example for future adaptation of public sector telemedicine efforts. Furthermore, the elderly with less educational attainment and lower socioeconomic status are usually the last to adopt technology; therefore, reaching these individuals will not be easy and require more effort or incentives. Additionally, insurance coverage for telemedicine is not mandatory, which excludes many older populations and retirees. For telemedicine to reach its full potential, these payment barriers must be removed, and this divide must be eliminated to ensure equitable access. All 10 business leaders whom we interviewed were in consensus that the lack of a regulatory framework was a key challenge for the development of the telemedicine market in Viet Nam. They all agreed that even with the best intentions and many advantages, telemedicine cannot meet all health care needs and can be misused. For example, studies have found telemedicine usually ends up with doctors being more likely to prescribe antibiotics. Furthermore, many health conditions require in-person visits. Therefore, clinical protocols and standards to determine how to handle each disease and each condition and who is eligible to provide telemedicine for each condition are needed. The clinical protocol should clearly state what types of cases still warrant face-to-face contact and what can be managed through remote consultations. In addition, quality assurance, reimbursement, and regulatory oversight are important factors in assuring patient safety and protection. Currently, most private telemedicine businesses are facing cost-recovery challenges and payment issues. Policy makers need to take into consideration the reimbursement mechanisms and incentives for telemedicine services. It is worth noting that the reimbursement issues for providers participating in the telemedicine business are currently the biggest obstacle to its adequate development and sustainability. Telemedicine businesses grew too fast to meet health care needs during the COVID-19 pandemic. As new care models were quickly rolled out, there may have been more focus on responding to an emergency and not enough attention to other important issues. For example, an issue that emerged under this review is data privacy and security. Due to the lack of a regulatory framework, providers face legal concerns and for this reason, they recorded the teleconsultation sessions in case they need evidence to defend a lawsuit. However, it is not clear whether clients are aware of this practice or how long the data will be stored by service providers. What is the risk of a potential data breach? This also needs to be included in the clinical guidelines and the regulatory framework. Patients should be informed that their teleconsultation session is being recorded, the risks present, and how long the data will be kept. 28 Another theme found in this review is the lack of women who are founders or leaders of telemedicine businesses. Of the 30 businesses listed, there were only two female founders/CEOs, and one female project lead (UNDP-funded). Of the 10 businesses being reviewed, there is only one female founder (of Docosan), Ms. Beth Lopez. It is important to consider this and to foster women’s participation and leadership in start-up businesses in general and in the health care sector specifically. Our conversation with Ms. Lopez clearly showed her dedication to improving women’s health, particularly reproductive health, and health issues facing the most vulnerable segments of the population. Ms. Lopez also expressed a strong desire to bring about social impact. Limitations This review has several limitations. First, the sampling frame was limited to known providers, and the actual review focused on only 10 providers that have operated for at least several years in the Viet Nam market. Their opinions and recommendations might not reflect the overall views of founders, managers, and employees of the telemedicine industry in Viet Nam. Further, due to the rapid review and limited time and resources, we were not able to interview users of these businesses. We, however, have researched literature and reviewed clients’ feedback on these telemedicine websites (where available). The overall findings and ratings from patients were extremely positive, indicating the great potential of telemedicine in improving health access and care quality. Future research is needed to purposefully include more businesses and patients who have used telemedicine services, as well as to evaluate the effectiveness, quality, and equity of telemedicine services. 29 CHAPTER 4: CONCLUSIONS AND RECOMMENDATIONS This rapid review paints a promising picture of the telemedicine market within the health care market in Viet Nam. In just five years, Viet Nam has seen considerable growth in the number of businesses (from 5 to more than 30), revenues, service offerings, and patient volume. Some businesses such as Hellobacsi have attracted 10 million viewers per year, while Docosan, JioHealth, eDoctor, Doctor Anywhere, and so on, each serve several thousand patients per month through their teleconsultation apps. Boosted and tested by the COVID-19 pandemic, telemedicine has shown its tremendous benefits and positive impact on the lives of patients. It offers convenient health care on the patient’s schedule, saving travel time, reducing wait time, offering options to choose doctors of preference, and reducing overall health care costs. Many previously thought barriers and limitations (quality concern, bandwidth, equity, etc.) of telemedicine have proved solvable. In many countries, health care leaders and policy makers have been able to find ways to address legal and payment issues, helping to sustain telemedicine postpandemic. Currently, telemedicine accounts for just 1 percent of the total health consultations in Viet Nam. Thus, there is a huge space for telemedicine to grow. Although, this review has limitations as it does not include patients’ responses to objectively access patient satisfaction and health outcomes, the optimism, aspirations, beliefs and innovative thinking of the leaders of these businesses have sent a message that telemedicine in Viet Nam will not just continue to exist but will grow and fill critical gaps in the health care infrastructure of Viet Nam. The review also sheds light on several key challenges, which are major obstacles to the development and sustainability of telemedicine in Viet Nam. These include the lack of a legal framework and guidelines on payers and insurance reimbursement; liability; and clinical protocols and standards for telemedicine practice, and because many Viet Namese are still new to this model of care and are therefore hesitant. Because of these challenges, telemedicine providers must strike a balance between affordability and sustainability while pricing their services, thus causing a negative impact on health care equity. Further, because telemedicine is still a new concept, providers will need to spend significant time and money on marketing and customer education to increase acceptance of remote health solutions. Lastly, due to high start-up costs, most of the businesses have not been able to be profitable and some are facing funding challenges. Showing value propositions through app innovations will attract both investors and clients/ patients. Based on the key findings, we make the following recommendations: 1. Establish a regulatory framework. o Telemedicine is evolving rapidly, and a regulatory framework must be established to keep up with its development [4, 5]. We recommend the following steps to establish such a framework. The first measure is launching a regulatory sandbox initiative, a legal classification that creates a space where participating businesses won’t be subject to onerous regulations for a limited amount of time.. This would allow start-ups to experiment with new solutions and allow policy makers to evaluate what’s working and what isn’t. o The second measure is to develop clinical guidelines for telemedicine practices to ensure quality of care and protect health workers and patients. These guidelines should also provide details on procedures for obtaining consent, ensuring the health 30 worker is a registered medical practitioner, and prescription management via telemedicine. It is critical to emphasize that such clinical protocols must be evidence- based and properly adapted to telemedicine and are easy to implement. o The third measure is to have clear guidance on paying for telemedicine services, pricing, and insurance reimbursement. Furthermore, for telemedicine services to be institutionalized, such services should ideally be incorporated into the overall health benefit packages. 2. Regularly use data to understand users’ insights and customer segmentations as a way to improve equitable access and to address disparities regarding gender, age, and socio-economic status. In addition, telemedicine often requires higher network bandwidth for accessibility compared to other digital health interventions. If the telemedicine service is to increase health care access to those who do not have it, careful consideration of the connectivity and building an internet network for rural and remote areas will be critical. In addition, pay special attention to the needs of disadvantaged groups, including people with low literacy or few digital literacy skills, people with limited control over or access to digital devices, people speaking minority languages, people with disabilities, and people who may face legal issues. These recommendations align with key findings from the latest Digital Health Report from the World Bank—Digital-in-Health: Unlocking the Value for Everyone (2023), which stresses the three areas that are essential for governments as they invest in digital health and telemedicine: prioritize, connect, and scale [22]. 3. Ensure that telemedicine should be able to integrate and exchange data (data interoperability) with other digital systems to ensure continuity of care and accountability. These may include electronic medical records and laboratory information systems. 4. Develop a well-defined data security plan for storing, transferring, and processing sensitive health information, and to manage access to clinical records for use during the telemedicine service implementation. The telemedicine services will also need to ensure patients are made aware of and consent to a recording of the telemedicine consultation for potential auditing and monitoring purposes. 5. As a new model of care, process and outcome evaluation of telemedicine models in Viet Nam will be needed. Evaluation findings will help generate evidence to guide policies and improve telemedicine practice. 31 ANNEX 1: List of telemedicine services in Viet Nam Business name Sector For more information 1 MOH’s telemedicine project Public www.benhviendaihocyhanoi.com in public hospitals 2 Doctor for Everyone project Public https://www.undp.org/Viet Nam/press- funded by UNDP releases/grassroots-telemedicine-phase-2- results-and-future-planning 3 Pham Ngoc Thach UMP’s Public www.phongkhamdaihocypnt.edu.vn Clinic 4 Public- VOVdoctor24 www.vovbacsi24.com Private 5 eDoctor Private www.edoctor.io 6 Jio Health Private www.jiohealth.com 7 DoctorAnywhere Private www.doctoranywhere.vn 8 MedOn/Medlatec Private www.medlatec.vn 9 Docosan Private www.docosan.com 10 Med247 Private www.med247.vn 11 Vmood Private www.vmood.org 12 Wellcare Private www.wellcare.vn 13 Dr.Psy Private www.drpsy.com.vn 14 AI Health Private www.aihealth.vn 15 YouMed Private www.youmed.vn 16 Safe & Sound Private www.sns.org.vn 17 Viet Radiology Private www.minerva-pacs.vn 18 TeleVital Private www.elcom.com.vn/san-pham/ai-televital 19 VinDr Private www.vindr.ai 20 OnSky Private www.onskyhealth.com.vn 21 Private www.tmainnovation.vn/giai-phap-theo-doi- mCare suc-khoe-tu-xa/ 22 Medigo Private www.medigoapp.com 23 Long Châu Pharmacy Private www.nhathuoclongchau.com.vn 24 BookingCare Private www.bookingcare.vn 25 Doctor4U Private www.doctor4u.vn 26 Menthy Private www.menthy.vn 27 HelloBacsi Private www.hellobacsi.vn 28 Alobacsi Private www.alobacsi.com 29 Medpro Private www.medpro.vn 30 IsofH Private https://isofh.com/ 32 REFERENCES 1. 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[Internet]. New York (NY): McKinsey and Company; 2021 Jul 9. 20. Chang JE, Lai AY, Gupta A, Nguyen AM, Berry CA, Shelley DR. Rapid transition to telehealth and the digital divide: implications for primary care access and equity in a post- 33 COVID era. Milbank Q. 2021;99(2): 340–68. 21. Bains J, Greenwald PW, Mulcare MR, et al. Utilizing telemedicine in a novel approach to COVID-19 management and patient experience in the emergency department. Telemed J E Health 2021; 27 (3): 254–60. 22. World Bank. 2023. Digital-in-Health: Unlocking the Value for Everyone. © Washington, DC: World Bank. http://hdl.handle.net/10986/40212 License: CC BY 4.0. 34 This review was conducted using secondary data combined with key informant interviews aiming to (1) understand the current state of telemedicine services in Viet Nam, their business models and challenges; and (2) provide recommendations to guide national-level policy makers on how to strengthen telemedicine services in Viet Nam. Over the past five years, Viet Nam has seen a moderate growth in the number of telemedicine services, revenues, service offerings, and patient volume. Furthermore, these services’ functionalities can be grouped in three major types: (1) providing access to a second opinion on imaging and diagnostic tests, especially for providers working at commune or district hospitals (disadvantaged/ lower level of care); (2) using teleconsultations to screen and triage patients, then move a small proportion of patients who need in-person visits to offline facilities; and (3) enabling digital provider-to provider consultations on certain disease conditions or diagnostics. The authors recommends the government of Viet Nam to urgently establish a regulatory framework to keep up with the rapid development of telemedicine services in the country, which includes clinical guidelines for telemedicine practices for ensuring quality of care and protecting health workers and patients. 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