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Telemedicine and Ancillary Healthcare Services with a Focus on Last-mile Delivery

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Telemedicine and Ancillary Healthcare Services with a Focus on Last-mile Delivery

Country
Sector
Most major industry classification systems use sources of revenue as their basis for classifying companies into specific sectors, subsectors and industries. In order to group like companies based on their sustainability-related risks and opportunities, SASB created the Sustainable Industry Classification System® (SICS®) and the classification of sectors, subsectors and industries in the SDG Investor Platform is based on SICS.
Health Care
Sub Sector
Most major industry classification systems use sources of revenue as their basis for classifying companies into specific sectors, subsectors and industries. In order to group like companies based on their sustainability-related risks and opportunities, SASB created the Sustainable Industry Classification System® (SICS®) and the classification of sectors, subsectors and industries in the SDG Investor Platform is based on SICS.
Health Care Providers
Indicative Return
Describes the rate of growth an investment is expected to generate within the IOA. The indicative return is identified for the IOA by establishing its Internal Rate of Return (IRR), Return of Investment (ROI) or Gross Profit Margin (GPM).
20% - 25% (in IRR)
Investment Timeframe
Describes the time period in which the IOA will pay-back the invested resources. The estimate is based on asset expected lifetime as the IOA will start generating accumulated positive cash-flows.
Medium Term (5–10 years)
Market Size
Describes the value of potential addressable market of the IOA. The market size is identified for the IOA by establishing the value in USD, identifying the Compound Annual Growth Rate (CAGR) or providing a numeric unit critical to the IOA.
USD 100 million - USD 1 billion
Average Ticket Size (USD)
Describes the USD amount for a typical investment required in the IOA.
> USD 10 million
Direct Impact
Describes the primary SDG(s) the IOA addresses.
Good health and well-being (SDG 3)
Indirect Impact
Describes the secondary SDG(s) the IOA addresses.
Gender Equality (SDG 5) No Poverty (SDG 1) Reduced Inequalities (SDG 10)

Business Model Description

Invest in B2C Aggregated HealthTech platforms which offer last mile connectivity with licensed doctors / healthcare professionals (via chat, video or voice calls), certified partner pharmacies through medical delivery service and licensed medical laboratory services (offering home-testing and sample collection services). Examples of companies active in this space are:

HaloDoc, founded in 2016, is a B2C HealthTech platform that provides teleconsultation, e-pharmacy and at-home lab services across Indonesia. Halodoc charges USD 2.45 for a 15 minutes session. It has been successful in raising >USD 100 mn, including USD 12 mn in a seed round (Go-Jek) and USD 13 mn in a Series A round (Singapore-based Clermont Group) (15).

PT Sumo Teknologi Solusi, founded in 2014, developed Alodokter offering 5 features: consultation, schedule appointment, doctor/hospital search, health articles, health protection (Alodokter Protection) and e-pharmacy. It raised USD 0.6mn (Seed), USD 2.5mn (Series A), USD 9 mn (Series B) and USD 30 mn (Series C) from Pegasus Tech Venture, Golden Gate, Softbank Ventures Asia and Sequis Life. (16)

Expected Impact

Provide access to quality and affordable health care services to underserved, unserved populations and vulnerable groups by leveraging digital platforms.

How is this information gathered?

Investment opportunities with potential to contribute to sustainable development are based on country-level SDG Investor Maps.

Disclaimer

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Country & Regions

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Country
Region
  • Indonesia: Countrywide
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Sector Classification

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Sector

Health Care

Development need
Below optimum referral system of healthcare services and lack of accessible quality health care has lead to an increase in unmet needs for healthcare from 4.66% (2015) to 5.44% (2020) (1), relatively high maternal mortality rate (MMR) (305/100,000 live births, 2015) and infant mortality rate (26.9/1,000 live births, 2015) (2).

Policy
Healthcare policy, under the National Priority (PN) 3: aims to improve human capital and competitiveness. Priority Program (PP) 3 and 2 cover the universal health coverage to address the maternal and infant mortality, communicable and non-communicable diseases, reproductive health and family planning (3).

Gender inequalities and marginalization issues
Maternal and infant mortality are among the highest among peer countries in Association of Southeast Asian Nations (ASEAN), caused by health and socioeconomic issues, such as child marriage practices in several regions (4).

According to the 2018 Socio-economic National Survey (Susenas), 1 of every 9 girls aged 20-24 gets married before the age of 18, i.e. ~1.2 mn girls, with Indonesia recording the 8th highest number of child marriages in the world (5).

Investment opportunities introduction
Healthcare spending in Indonesia was USD 38.3 bn [or USD 112 per capita (5)], i.e. 3.6% of GDP, (6) and USD 21 bn in 2019 (7). It is expected to reach USD 51 bn by 2020 (4.18% of GDP) (8).

Key bottlenecks introduction
Last-mile connectivity has been challenging since Indonesia is an archipelago with a geographically fragmented population. Availability and recruitment of quality healthcare personnel has also been a problem across the country.

Sub Sector

Health Care Providers

Development need
Community Health Centers (CHC-Puskesmas) and private Primary-Level Health Facilities (FKTP) have not been able to function optimally as gate keepers to institutional healthcare (9) and respond to Covid-19. (10) In 2020, only 39.9% of the CHCs had adequate skilled health workers. (1) >50% of doctors work in Java (11).

Policy priority
Ministry of Health (MoH) Strategic Plan (2020-2024): focuses on improving the coverage/quality of antenatal, neonatal, delivery and postpartum services.

It also includes strengthening the health system with innovation/technology, including expansion of online referral system, integration of private health facilities in the referral system, development of telemedicine services, digitization of medical records. (12)

Gender inequalities and marginalization issues
Neonatal mortality is higher in rural areas than in urban areas, exacerbated due to lack of access to quality healthcare services (2). High cost and long duration of commute for accessing health facilities result in delays which threaten the patient's life. (13)

Hospitals/health centers in remote areas do not have specialized doctors to provide quality healthcare services. (13)

Investment opportunities introduction
During Covid-19, the switch from face-to-face to online consultations led to a 600% surge in the use of telemedicine applications, including those developed by electronic health startups and hospitals. In 2020, the number of people accessing telemedicine applications for information about the coronavirus reached 15 mn. (14)

Key bottlenecks introduction
Asymmetric information and low National Health Insurance (NHI) penetration rates are a major hindrance to accessing quality health services and medicine. Indonesians, especially those living in rural areas have access to low quality primary healthcare services and almost non-existent secondary specialized care.

Industry

Health Care Delivery

Pipeline Opportunity

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Investment Opportunity Area

Telemedicine and Ancillary Healthcare Services with a Focus on Last-mile Delivery

Business Model

Invest in B2C Aggregated HealthTech platforms which offer last mile connectivity with licensed doctors / healthcare professionals (via chat, video or voice calls), certified partner pharmacies through medical delivery service and licensed medical laboratory services (offering home-testing and sample collection services). Examples of companies active in this space are:

HaloDoc, founded in 2016, is a B2C HealthTech platform that provides teleconsultation, e-pharmacy and at-home lab services across Indonesia. Halodoc charges USD 2.45 for a 15 minutes session. It has been successful in raising >USD 100 mn, including USD 12 mn in a seed round (Go-Jek) and USD 13 mn in a Series A round (Singapore-based Clermont Group) (15).

PT Sumo Teknologi Solusi, founded in 2014, developed Alodokter offering 5 features: consultation, schedule appointment, doctor/hospital search, health articles, health protection (Alodokter Protection) and e-pharmacy. It raised USD 0.6mn (Seed), USD 2.5mn (Series A), USD 9 mn (Series B) and USD 30 mn (Series C) from Pegasus Tech Venture, Golden Gate, Softbank Ventures Asia and Sequis Life. (16)

Business Case

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Market Size and Environment

Market Size (USD)
Describes the value in USD of a potential addressable market of the IOA.

USD 100 million - USD 1 billion

CAGR
Describes the historical or expected annual growth of revenues in the IOA market.

> 25%

Critical IOA Unit
Describes a complementary market sizing measure exemplifying the opportunities with the IOA.

Smartphone users: 67% -2020; 239 mn-2026 (18) Internet penetration %: 69.8-2020; 82.53-2026 (19)

Growth of digital healthcare platforms seems reasonable given Indonesia’s high internet penetration rate of 64.8%. It is expected to reach 89.3% by 2025, with over 200 mn users (20). Healthcare spending in Indonesia was USD 38.3 bn in 2018 (3.6% of Gross Domestic Product or GDP) and is expected to reach USD 51 bn by 2020 (4.18% of GDP) (21).

Indonesia dominates the South East Asian market for telemedicine with the largest revenue share of 25.2% in 2020, owing to widespread adoption of telehealth services amidst the ongoing Covid-19. (22)

Indicative Return

IRR
Describes an expected annual rate of growth of the IOA investment.

20% - 25%

Digital health revenue is expected to grow from USD 85 mn in 2017 to USD 973 mn in 2023. (6) Halodoc: Gross Merchandise Value in Q4-2019 stood at USD 44.6mn (2) Alodokter: Revenue in 2021 was USD 60.2mn (3)

Since 2019, earnings for pharmaceuticals industry grew by 11% p.a. and revenue grew by 12% p.a. Industry is trading >3-year average Price-earnings (PE) ratio of 16.9x, expecting annual earnings growth of 0.5% over the next 5 years. (4) Such results will also impact the e-pharmacy segment.

Private Equity firms target 20-25% IRRs on their investment. Returns depend on stage of investment and the valuation at the time of exit. Example: Seed fund investors will earn a better return if they hold their investment, than the investors who enter at a later stage.

Investment Timeframe

Timeframe
Describes the time period in which the IOA will pay-back the invested resources. The estimate is based on asset expected lifetime as the IOA will start generating accumulated positive cash-flows.

Medium Term (5–10 years)

Telehealth results in cost saving for the health system, and the breakeven point can range from 1-9 years. Remote monitoring and store-and-forward services can reach their breakeven points sooner than the videoconference services. (23)

Halodoc, started in 2016, intends to launch its IPO in the next 2-3 years (15) Alodokter raised USD 0.6 mn (seed round) from Pegasus Tech Venture and Golden Gate; USD 2.5 mn (Series A) from Golden Gate; USD 9 mn (Series B) from Softbank Ventures Asia and USD 30 mn (Series C) from Sequis Life. (16)

Covid-19 has accelerated investment in digital health, fueling further innovation, with 3x the level of venture capital investment in digital health in 2020, than in 2017. (25)

Ticket Size

Average Ticket Size (USD)
Describes the USD amount for a typical investment required in the IOA.

> USD 10 million

Market Risks & Scale Obstacles

Market - Volatile

Digital health market in Indonesia is in a nascent stage and it is difficult to determine the willingness to pay by customers. ~91% of consumers would use digital health services if the costs are covered by employer or insurance provider. (26)

There is a lack of clarity on regulations which control the standards and quality of telemedicine services, especially those provided by digital health platforms. (27)

Model can only be successful in regions with a high internet penetration rate, supported by efficient data or internet infrastructure.

Impact Case

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Sustainable Development Need

Lack of access to quality healthcare services due to absence of healthcare providers and geographical barriers. There are only 3 doctors per 10,000 Indonesians. This shortage of medical practitioners and low access to expert medical advice, limits access to healthcare for those in need. (29)

Due to shortage of proper healthcare available (accessibility and quality) and high costs involved (23) also exacerbated by Covid-19, the unmet needs (of the population) for healthcare in Indonesia has increased from 4.66% in 2015 to 5.44% in 2020. (30)

Covid-19 raised public awareness of the quality of healthcare system. Although household spending decreased by -2.23% YoY in Q1-2021, the health and education related spending grew by 0.31% YoY in Q1-2021, depicting that people are increasingly prioritizing health consumption. (31)

Gender & Marginalisation

The communities in remote areas do not have access to quality health-care. Unmet needs for healthcare in rural areas is 6.16% as compared to 5.44% of total population as of 2020. (30)

Women who are married at a younger age have a higher risk of mortality during childbirth. The skilled birth attendance (95.16% in 2020 for 15-49 years married women) (30) should be increased significantly to achieve maternal mortality reduction by 2030. (2)

Indonesia is ranked 9th for highest Low Birth Weight (LBR) newborns. ~15% newborns suffer from low nutrition with weight <2.5kg. (32) >1/2 of infant mortality occur in the neonatal period, which is avoidable with quality of care (delivery and child birth) and timely immunization. (2)

Expected Development Outcome

Efficient (quality and timely care at affordable prices, improved accessability) healthcare services; Improved Covid-19 handling and mitigation accompanied by lab services offered by such platforms; Improved referral systems; BPJS, Health Social Security Agency's operational cost efficiency.

Increased transparency through real time digital payment systems, and potential outcomes for the environment through reduced CO2 emissions through reduced dependence on transportation for healthcare access.

Increased domestic production of medicines and medical devices to improve access to quality and affordable pharmacy products and medical devices. (2)

Gender & Marginalisation

Improved access to healthcare services to unserved and underserved population segments particularly beyond urban areas; potential reduction in maternal mortality rates; access to health-seeking information by women to improve awareness of reproductive healthcare and options therein.

Reduce the burden of overloaded hospitals across the country, (33) especially in regions with a limited number of doctors, (11) by offering ease of doctor consultations and drug delivery services at affordable rates through digital platforms.

Increasing early referral rates and timely detection of risk factors that have the potential to cause intra-uterine stunting can help in reducing maternal and infant mortality rate. (34)

Primary SDGs addressed

Good health and well-being (SDG 3)
3 - Good Health and Well-Being

3.8.1 Coverage of essential health services

3.1.1 Maternal mortality ratio

3.2.1 Under‑5 mortality rate

3.2.2 Neonatal mortality rate

3.b.3 Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis

Current Value

Penetration of the national insurance industry increased during Covid-19 to 3.11% In July 2021 from 2.92% in end of 2020. Total premiums for general and life insurance distributed through digital (InsurTech) reached ~USD 416.3 mn as of July 2021 (35).

305 per 100,000 live births (2015) (30)

32 per 1,000 live births (2017) (30)

15 per 1,000 live births (2017) (30)

92.12% in 2020 Vs. 79.38% in 2015. (30)

Target Value

Not available as on January-2022

2030: 131 (intervention scenario); 210 (BAU) (2)

2030: 7.0 (intervention scenario); 11.2 (BAU) (2)

2030: 7.0 (intervention scenario); 11.2 (BAU) (2)

94% in 2023, 96 % in 2024 (2)

Secondary SDGs addressed

5 - Gender Equality
1 - No Poverty
10 - Reduced Inequalities

Directly impacted stakeholders

People

Underserved and unserved areas and regions benefit from HealthTech platforms that focus on last mile connectivity.

Gender inequality and/or marginalization

Tele-ultrasound is used to help diagnose pregnant women who are in remote areas and is associated with obgyn specialists to speed up referrals. (37)

Planet

Reduce environmental burden as companies can leverage technology for reaching customers thereby reducing use of transport facilities that are significant emitters of Greenhouse gas (GHG).

Corporates

Reduced burden on Hospitals (~1,800 private hospitals and 1.000 public hospitals) for routine-care. Telemedicine companies benefit from lower operating costs (than in brick-and-mortar models) and are able to access the untapped market potential through last-mile reach of their platforms (36).

Public sector

With last-mile reach of business models, government benefits from reduced inequalities resulting from improved access of constituents to good quality healthcare, fulfil commitments around Universal Healthcare coverage.

Indirectly impacted stakeholders

People

Households and communities benefit from improved access to healthcare, improved quality of life and lowering of negative coping mechanisms to manage healthcare emergencies.

Gender inequality and/or marginalization

Telemedicine can help in reducing gender and regional divide by ensuring last-mile reach of quality healthcare.

Planet

Reduction in GHG emissions because of reduced burden on transportation services to access healthcare facilities.

Public sector

Healthier population results in a more productive workforce improved quality of human capital contributing to economic gains for the country.

Outcome Risks

Care provision with less than ideal information or misinformation may result in adverse results.

Lack of proper internet connectivity or weak infrastructure may result in a bias towards “best-connected” demographic (urban, middle class).

Emergency support or retrieval care may not be easily available in remote areas.

Provision of low cost services can impact the quality of healthcare staff available for providing consultations, thereby impacting the health of patients.

Gender inequality and/or marginalization risk: Vulnerable sections of the community may require additional financial assistance (concessional prices or lending support) to make use of the platform.

Impact Risks

Cyber crime that may target users from low resource settings (women, people with disability and low-income population) with limited information on registering grievances or on complaint mechanisms.

Availability of modern healthcare may result in elimination of local values and wisdoms. Example: traditional midwives' role may get eliminated resulting in growth in unemployment).

Fragmented healthcare value chain may result in ineffective health management if online consultation is not followed by expert care services.

Gender inequality and/or marginalization risk: Pregnant women may require real-time access to healthcare facilities which may not be readily available in remote areas without internet connectivity.

Impact Classification

C—Contribute to Solutions

What

Efficient access to quality healthcare services in terms of costs incurred and time consumed

Risk

Utilization of digital technology without adequate customer protection measures may expose customers to cyber crime/fraud.

Contribution

Telemedicine can help in ensuring last-mile reach of quality healthcare facilities with trained workers. In 2020, only 39.9% of the CHCs had adequate skilled health workers (17).

Impact Thesis

Provide access to quality and affordable health care services to underserved, unserved populations and vulnerable groups by leveraging digital platforms.

Enabling Environment

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Policy Environment

Rencana aksi program 2020-2024 MoH: GoI will increase the availability and quality of basic and referral health facilities implemented through a strategy of expanding coverage and developing telemedicine services, digitizing medical records and online medical records (12).

MoH issued Decree No. HK.01.07/ MENKES/ 650/ 2017: stating that hospitals and CHCs should administer a telemedicine service program trial. Stronger CHC presence can scaffold telemedicine by providing physical access to action advice received through consultations (38).

State Budget 2022: GoI has allocated USD 17.8 bn (~9.4% of the 2022 Budget) for health sector, focused on vaccination drive, intensify 3T (testing, tracing, and treatment) measures, hospital fees reimbursement for Covid-19 patients, supply medication and incentives for medical workers. (39)

Financial Environment

Financial incentives: Decree Of The Minister Of Health Of The Republic Of Indonesia Number Hk.01.07/Menkes/4829/2021 states that financing for online monitoring through telemedicine for COVID-19 patients (who are self-isolating), includes consultation and monitoring fee, and drug service fee (38).

Fiscal incentives: Cost of medicine services through telemedicine are reimbursed and charged to the State Revenue and Expenditure Budget as per the cooperation agreement between the MoH and pharmaceutical service facilities (appointed by MoH) in accordance with the provisions of the legislation (39).

Regulatory Environment

MOH Regulation No.90/2015L: briefly mentions Telemedicine to support health services in remote areas to increase the accuracy of and accelerate the process of medical diagnoses, and other health service facilities in areas which lack health workers (40).

MoH Regulation 20/2019: defines telemedicine as the provision of long-distance health services by health professionals utilizing information and communication technology (41).

MoH Regulation 20/2019: Such services consist of information exchange on diagnosis, medication, disease and injury prevention, research and evaluation, and sustainable education of health service providers in order to improve individual and public health (41).

Marketplace Participants

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Private Sector

Corporates: Klinik Pintar IDI, PT Medika Nuswantara Digital, PT. Jejaring Tiga Artha (Zi Care), PT Sumo Teknologi Solusi (Alodokter), PT Pintar Data Group Investors: PT Asuransi Jiwa Sequis Life; Golden Gate Ventures Pte. Ltd.; SkyStar Ventures; Gaido Group; 5Digital Ventures

Government

Ministry of Health; Ministry of Investment (Investment Coordinating Board); BPJS Health, Ministry of Women Empowerment and Child Protection, Ministry of Finance

Multilaterals

World Health Organization (WHO), United Nations Development Programme (UNDP), UN Women, United Nations Children's Fund (UNICEF), Asian Development Bank (ADB), World Bank (WB), GIZ, United Nations Population Fund (UNFPA)

Non-Profit

Aliansi Telemedik Indonesia (ATENSI) /Indonesian Telemedicine Alliance

Target Locations

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rural

Indonesia: Countrywide

Businesses should be able to reach last-mile customers across the country, especially to provinces that remain highly underserved.

References

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