Telemedicine implementation and healthcare utilization in Rwanda: interrupted time series of babyl digital health services from 2015 to 2024.

Abstract

BACKGROUND: Digital health platforms are transforming primary care delivery in low- and middle-income countries. Babyl provided Rwanda’s first nationwide telemedicine service from 2019 to September 2023, integrating nurse-led triage with physician oversight, e-prescriptions, and national health insurance. Despite processing 3.9 million consultations, evidence on population-level impacts of scaled telemedicine services like Babyl in sub-Saharan Africa remains limited. This study aimed to quantify the association between national-scale telemedicine implementation and facility-based healthcare utilization for common primary care conditions in Rwanda, using interrupted time series analysis to estimate immediate and sustained effects across introduction and discontinuation periods. METHODS: We integrated deidentified administrative data from Babyl (n = 3,899,788 consultations), Rwanda’s Health Management Information System (2015–2024). We employed two analytical approaches: (1) descriptive analysis of user demographics, insurance coverage, and clinical characteristics; (2) segmented regression with interrupted time series modeling using ordinary least squares with Newey-West heteroskedasticity- and autocorrelation-consistent standard errors to quantify level and slope changes across pre-intervention, intervention, and post-discontinuation periods for gastritis, diarrhea, urinary tract infections, malaria, and respiratory infections. RESULTS: The platform recorded 3.90 million consultations (2019–2023), with 75.4% covered by community-based health insurance and 54.7% among female patients. Task-shifting was substantial: triage nurses managed 44.2% of consultations, senior nurses 25.6%, and general practitioners 30.2%. Interrupted time series analysis revealed immediate reductions in facility-based cases following Babyl’s introduction: respiratory infections decreased by 1055 cases (95% CI -1098 to -1011; P < .001), malaria by 246 cases (95% CI -258 to -234; P < .001), gastritis by 137 cases (95% CI -146 to -127; P < .001), and urinary tract infections by 114 cases (95% CI -124 to -105; P < .001). Post-discontinuation, monthly increases ranged from 1 case (gastritis, diarrhea, urinary tract infections) to 10 cases (respiratory infections), suggesting demand reversal to facilities. CONCLUSIONS: National-scale telemedicine implementation was associated with substantial reductions in facility-based consultations for common conditions and successful task-shifting to nurses. The post-discontinuation reversal patterns underscore telemedicine’s role in healthcare access. Future digital health initiatives should prioritize sustainable financing, system interoperability, and regulatory frameworks to maintain service continuity.