Digital Primary Health in Rwanda: Qualitative Study of User Experiences and Implementation Lessons From Babyl's...

Digital health innovations address health care accessibility challenges in low- and middle-income countries. Babyl, Rwanda's largest telemedicine platform, reached 450 of 510 health facilities and enrolled 2 million patients before halting in September 2023 for system redesign. Limited research has explored implementation experiences and user perspectives that influenced its sustainability.

This study aims to explore user experiences and implementation lessons from Babyl's digital health platform, examining drivers that supported or hindered adoption and scale-up. This qualitative study uniquely examines the lived experiences of diverse stakeholders, active users, lapsed users, nonusers, health care providers, and Babyl agents to understand implementation challenges that contributed to the platform's halt.

A qualitative, cross-sectional study used 20 focus group discussions (FGDs) and 32 key informant interviews (KIIs) across 12 health centers in ten districts with diverse utilization rates, geographic locations, and Babyl agent availability. FGDs captured collective community perspectives while KIIs provided in-depth individual experiences, enabling data triangulation. FGDs included active users, lapsed users, registered nonusers, and eligible nonregistrants. KIIs involved health center heads, health care providers, and Babyl agents. Data were analyzed using thematic analysis following Braun and Clarke's framework. Data saturation was achieved when no new themes emerged from the last 3 FGDs and 5 KIIs. All transcripts were validated through member checking with a subset of participants, and intercoder reliability was established with a Cohen kappa of 0.82 across 2 independent coders.

Five themes emerged: (1) knowledge and perceptions of digital health, (2) enablers and barriers to utilization, (3) experience and satisfaction, (4) benefits, and (5) improvement suggestions. Participants held positive perceptions of digital health for improving access and reducing wait times. Key enablers included qualified providers, convenience, privacy, and Babyl agents. Major barriers included negative perceptions of remote care quality, service delays, limited digital literacy, device access challenges, and inadequate health facility integration. Users reported high satisfaction with consultations but experienced process confusion. Patient and provider perspectives diverged: patients emphasized convenience, while providers expressed concerns about diagnostic limitations without physical examination. Digital literacy and smartphone access were pronounced barriers among rural and older participants. Recommendations included community mobilization, universal agent deployment, expanded coverage, and sustainable financing.

Multiple implementation challenges at individual, community, health system, and policy levels contributed to Babyl's discontinuation. Critical lessons include the importance of genuine health system integration, sustainable financing, stakeholder engagement, and gradual scaling. Findings provide insights for Rwanda's health sector digitalization and other African nations investing in telemedicine platforms.