JMIR Publications

ABSTRACT

Background:

Digital health innovations represent critical solutions for addressing healthcare accessibility challenges in low- and middle-income countries. Babyl, Rwanda's largest telemedicine platform, reached 450 of 510 primary health facilities and enrolled two million patients before being halted in September 2023 as the system underwent redesign. Despite its extensive scale and initial success, limited research has explored the implementation experiences and user perspectives that influenced its sustainability.

Objective:

This study aimed to explore user experiences and implementation lessons from Babyl's large-scale digital health platform in Rwanda, examining key drivers that supported or hindered the adoption and scale-up of digital health services.

Methods:

A qualitative, cross-sectional study was conducted using focus group discussions (FGDs) and key informant interviews (KIIs) across twelve health centers in ten districts representing diverse utilization rates, geographic locations, and Babyl agent availability. Twenty FGDs included active users, lapsed users, registered non-users, and eligible non-registrants. Thirty-two KIIs involved health center heads, healthcare providers, and Babyl agents. Data were analyzed using iterative, inductive thematic analysis following Braun and Clarke's six-phase framework.

Results:

Five major themes emerged: (1) knowledge and perceptions of digital health services, (2) enablers and barriers to digital service utilization, (3) experience and satisfaction using Babyl services, (4) benefits of digital services, and (5) suggestions for service improvement. Participants generally held positive perceptions of digital health services and recognized their potential to improve healthcare access and reduce waiting times. Key enablers included qualified providers, convenience, privacy, and the presence of Babyl agents. Major barriers encompassed negative perceptions about remote care quality, service delays, limited digital literacy, device access challenges, and inadequate integration with health facility workflows. Users reported high satisfaction with clinical consultations but experienced confusion with service processes. Recommendations emphasized community-level mobilization, universal Babyl agent deployment, expanded service coverage, and sustainable financing models.

Conclusions:

While Babyl demonstrated significant potential for improving healthcare accessibility in Rwanda, multiple implementation challenges at individual, community, health system, and policy levels contributed to the decision to halt and redesign the system. Critical lessons for future digital health implementations include the importance of genuine health system integration, sustainable financing models, stakeholder engagement, and gradual scaling approaches. The study provides valuable insights for designing more effective and sustainable digital health interventions in similar low- and middle-income country contexts.