Introduction

The advancement of digital technology has brought significant changes to healthcare systems worldwide, including in Indonesia. The digitalization of healthcare services has expanded access to medical information, teleconsultation, and pharmaceutical services, while also reshaping the way patients interact with healthcare providers and obtain treatment. Digital health platforms, commonly referred to as health-tech, have emerged as important actors in improving accessibility and efficiency in healthcare delivery, particularly in countries where disparities in infrastructure and service distribution remain evident (1, 2).

In recent years, digital health startups have increasingly played a role in addressing structural challenges such as uneven logistical infrastructure, regulatory constraints, and limited access to healthcare services in certain regions. Studies have shown that the integration of digital platforms, pharmaceutical services, and telemedicine can enhance service accessibility and patient engagement, particularly when supported by user-centered service models and effective communication channels (3, 4). At the policy level, digital health initiatives have also been recognized as part of broader national healthcare transformation strategies aimed at improving system efficiency and accessibility (5).

The transformation of digital health services is closely related to the concept of business model innovation, which refers to how organizations create, deliver, and capture value through the configuration of resources, activities, and partnerships (6, 7). In highly dynamic and regulated sectors such as healthcare, startups must continuously adapt their business models to technological change, regulatory requirements, and evolving consumer expectations. Research on digital transformation in healthcare emphasizes that organizational flexibility, service integration, and adaptive strategies are critical for sustaining operations in rapidly changing environments (8, 9) .

Despite the growing literature on digital health and business model innovation, much of the existing research focuses on large platforms, telemedicine adoption, or national-level policy frameworks. Empirical studies that examine how digital health startups adapt their business models at the organizational and operational levels remain relatively limited, particularly in emerging markets and Southeast Asian contexts. Furthermore, previous studies often discuss digital health transformation conceptually but provide limited qualitative evidence on how adaptation processes occur in practice within resource-constrained organizations.

To address this gap, this study explores the case of HonestDocs, a digital health platform operating in Indonesia that provides online healthcare services, including access to medications, clinical services, and health education through digital communication channels. Rather than assuming organizational success, this research aims to analyze how business model adaptation is carried out, what operational and organizational mechanisms support this process, and how external constraints such as regulations and logistical limitations influence strategic decision-making.

This study is guided by the following research questions: 1) How does a digital health startup adapt its business model in response to technological, regulatory, and logistical constraints?, 2) What organizational practices and operational strategies support business model adaptation in this context?

The analysis is informed by the concept of business model innovation as an analytical framework to understand how value creation and service delivery are structured within digital platforms (7). In addition, this study draws on perspectives related to organizational adaptability and digital health transformation, which emphasize the importance of flexibility, learning, and responsiveness in uncertain and resource-constrained environments (8, 9). These theoretical perspectives are used as analytical lenses to interpret empirical findings rather than as normative benchmarks of performance.

By applying a qualitative case study approach, this research contributes to the literature in three ways. First, it provides empirical insights into business model adaptation in a digital health startup operating in a developing country context. Second, it highlights the role of organizational practices and operational strategies in shaping adaptive responses to regulatory and logistical constraints. Third, it offers exploratory insights that may inform future comparative studies on digital health platforms in emerging markets.

The remainder of this paper is organized as follows. The next section describes the research methodology, followed by the presentation of results and discussion, and finally the conclusion and implications.

Methodology

Research Design

This study employed a qualitative exploratory approach using a single case study design to examine business model adaptation in a digital health startup. A case study approach was selected because it allows an in-depth understanding of complex organizational processes and strategic decision-making within their real-life context, particularly in emerging sectors such as digital health where empirical research remains limited. HonestDocs was chosen as the case because it represents a digital health startup operating in a highly regulated environment and using a hybrid service model that combines digital platforms, logistics, and personalized customer support, making it a relevant and information-rich case for examining business model adaptation.

Participants and Data Collection

Data were collected through semi-structured, in-depth interviews with three key informants who held strategic managerial roles within the organization, namely the Director and Founder, the Vice President of Marketing, and the Head of Operations. These informants were selected purposively because they were directly involved in strategic planning, operational decision-making, service development, and were therefore able to provide detailed insights into organizational processes and adaptation strategies. In qualitative case study research, a small number of key informants is considered appropriate when participants possess high levels of contextual knowledge and when the objective is analytical depth rather than statistical generalization (10, 11).

An interview protocol was developed to guide the data collection process. The protocol included open-ended questions related to business model development, operational challenges, regulatory constraints, technological choices, and organizational practices. The full interview protocol is provided as supplementary material. Each interview was conducted in a semi-structured format to allow flexibility while maintaining consistency across participants. Interviews were recorded with participant consent and transcribed verbatim for analysis.

Data Analysis

The data were analyzed using thematic analysis following the procedures proposed by Braun and Clarke, which include data familiarization, initial coding, searching for themes, reviewing themes, defining and naming themes, and producing the report (12). Coding was conducted iteratively to identify recurring patterns related to adaptation strategies, organizational practices, and external constraints. Data organization and coding were supported using NVivo version 12 (QSR International Pty Ltd., Melbourne, Australia). This inductive approach allows themes to emerge from participants’ perspectives rather than being imposed from predefined theoretical categories.

Trustworthiness and Limitations

To enhance credibility and trustworthiness, data triangulation was conducted by comparing interview findings with internal company materials, including standard operating procedures, service workflow descriptions, and operational reports. The triangulation process involved systematically cross-checking key statements from interview transcripts with documentary evidence to confirm consistency of information and identify any discrepancies. This process was carried out independently by the research team, and any differences in interpretation were discussed until consensus was reached. These documents were used to corroborate statements made by informants and to provide contextual understanding of organizational processes. In addition, the researchers maintained reflective notes during analysis to minimize interpretive bias and to ensure consistency in theme development.

This study has several limitations. The findings are based on a single case and rely primarily on managerial perspectives, which may introduce elite bias and limit the diversity of viewpoints. The absence of external stakeholders, such as customers or regulators, also constrains the breadth of triangulation. Therefore, the results should be interpreted as exploratory insights rather than generalizable conclusions. Future studies are encouraged to include multiple cases and broader stakeholder perspectives to strengthen external validity. Comparative cases and mixed data could deepen understanding of digital health business model adaptation.

Results and Discussion

HonestDocs Business Model

HonestDocs has developed a platform-based business model that integrates medication delivery services and access to clinical appointment bookings. Its key strengths lie in its low-barrier access model, in which users are not required to install a dedicated proprietary application, as services are primarily delivered through widely used messaging platforms. The success of digital healthcare services is largely determined by accessibility and user experience (13). Themes were developed through an inductive coding process. Initial codes were generated from interview transcripts and then grouped into broader themes based on conceptual similarity and recurring patterns. The number of codes shown in the table does not indicate statistical significance but is presented only to illustrate the relative occurrence of issues discussed by informants. The qualitative data analysis generated several main themes, as presented in Table 1.

The themes presented in Table 1 and Table 2 represent patterns identified during the coding process and are used as an analytical framework for interpreting the findings. These themes do not represent quantitative measures of importance but rather recurring issues discussed across interviews.

The relationship between the theme and the code results of the interview with HonestDoc is illustrated in Table 2.

Interview findings suggest that HonestDocs builds its business model around flexibility and relatively minimalist technological infrastructure. Informants described a low-barrier access model service model in which transactions and consultations are conducted through messaging platforms, which, according to their accounts, may facilitate access for users with limited digital literacy. Previous studies have noted that simplified digital health systems and low-barrier communication channels can improve accessibility in certain contexts (13). However, the present study does not directly assess service outcomes or user experience, and therefore these observations should be interpreted cautiously.

“We focus on technology that doesn’t burden users. No app, no complicated login. They can place orders directly through WhatsApp.” - Informant A

Interview data also indicate that the organization faces challenges related to restrictions on digital pharmaceutical advertising, variations in logistics quality, and distribution gaps outside Java. These challenges are closely linked to the regulatory and infrastructural characteristics of healthcare systems in emerging markets. In many countries, including Indonesia, pharmaceutical promotion through digital platforms is strictly regulated to prevent inappropriate drug marketing and protect patient safety. As a result, digital health providers often encounter limitations in online advertising and must adjust their communication strategies to comply with platform and regulatory requirements.

To address these constraints, informants described several adaptive strategies. Instead of relying heavily on paid digital advertising, the organization emphasized educational content, personalized communication, and organic engagement through messaging platforms and social media. This approach allowed the organization to maintain visibility and patient engagement while remaining compliant with advertising policies strictly. Previous studies have reported that content-based engagement and trust-building["Table", "Table 1. Results of thematic analysis.", "8pt", "2", "false"] ["Table", "Table 2. Summary of themes and illustrative codes from thematic analysis.", "8pt", "2", "false"]communication can be effective alternatives to conventional digital advertising in healthcare services, particularly in regulated environments.

Variations in logistics quality and distribution gaps outside major urban areas were also identified as operational challenges. These issues are partly related to disparities in transportation infrastructure, pharmaceutical supply chains, and service provider networks across regions. To mitigate these constraints, informants reported that the organization adopted flexible logistics partnerships and adjusted delivery workflows depending on regional availability and service capacity. Similar adaptive logistics strategies have been documented in digital health and e-commerce platforms operating in geographically dispersed markets, where collaboration with multiple local partners is often necessary to maintain service continuity. These constraints were described by informants as factors that influence operational decisions. Similar regulatory and structural challenges have been reported in studies of digital health ecosystems in developing countries, where tensions often exist between innovation and regulatory frameworks (1, 14).

“Google can reject our ads just because they contain pharmaceutical terms. We have to find creative ways to educate people.” - Informant B

Another theme emerging from the interviews relates to personalized customer assistance and educational communication practices. Informants perceived these approaches as important for facilitating interaction with users, particularly those requiring additional support in understanding health-related information. Previous research suggests that interpersonal communication and human assistance in digital services may contribute to user engagement and trust, especially in healthcare settings (3, 4). Nevertheless, this study does not include direct data from users, and therefore conclusions regarding user trust remain indicative rather than definitive.

“We apply the 5W1H and 3PQ methods to answer every patient’s question - as if they have their own personal assistant.” - Informant C

Interview findings further indicate that the organization has explored various forms of service integration, including consultation, medication delivery, and health-related information services. From an analytical perspective, this pattern may be interpreted in relation to the concept of platform-based service integration, where value creation occurs through linking complementary services (7). Global health policy literature also highlights the importance of integrated service models in improving access to healthcare services (15). However, the present study does not evaluate the long-term effectiveness or financial performance of these initiatives.

“Our goal is to become the first-place people think of when they need digital healthcare services - from education to installment payments for medication.” - Informant A

Finally, informants described organizational practices such as collaborative decision-making and relatively flexible communication structures. These practices were perceived internally as supporting operational responsiveness. Previous studies on agile organizational practices suggest that decentralized decision-making and rapid feedback mechanisms may facilitate adaptation in dynamic environments (16). However, because the findings are based on self-reported managerial perspectives, they should be interpreted as exploratory insights rather than objective measures of organizational effectiveness.

“We don’t have lengthy bureaucracy. If a staff member has a good idea, it can be implemented immediately together.” - Informant B

Business Model Characteristics of HonestDocs

The thematic analysis identified several recurring patterns related to business model configuration, operational practices, and external constraints. The main themes that emerged from the coding process include business model flexibility, regulatory and logistical challenges, human-centered service practices, service integration, and organizational culture.

Interview data suggest that HonestDocs relies on relatively lightweight technological infrastructure and communication-based service delivery. Transactions and consultations are frequently conducted through messaging platforms, which, according to informants, help reduce barriers for users with limited digital literacy. This finding indicates that accessibility considerations may play an important role in shaping operational decisions in digital health startups operating in emerging markets.

Previous studies have reported that the use of simple communication technologies, including mobile messaging and low-bandwidth digital tools, can improve accessibility and service reach, particularly in contexts where digital literacy and infrastructure remain uneven (17, 18). Similarly, research on digital health adoption emphasizes that ease of access and user experience are critical factors influencing service utilization in healthcare platforms (13). However, the present study does not measure service outcomes or user satisfaction directly, and therefore the effectiveness of this approach cannot be evaluated quantitatively.

Regulatory and Operational Constraints

Informants described difficulties related to pharmaceutical advertising restrictions and variations in drug distribution infrastructure across regions. These variations include differences in the availability of partner pharmacies, delivery network coverage, transportation infrastructure, and supply chain reliability between major urban areas and smaller cities or rural regions. In some areas, limited pharmacy networks and longer delivery routes may lead to delays, higher logistics costs, and less consistent service delivery.

These conditions create operational challenges for digital health platforms, which rely on timely medication delivery to maintain service quality and patient trust. To manage these constraints, informants reported adopting flexible logistics arrangements, including collaborating with different courier partners, adjusting delivery workflows, and prioritizing regions with more stable supply chains.

Similar patterns have been reported in studies of digital health and e-pharmacy services in emerging markets, where uneven infrastructure and fragmented supply chains influence service accessibility and operational efficiency. These findings also suggest that digital health startups often operate within regulatory and infrastructural environments that require continuous adaptation of operational strategies, particularly in settings where regulatory frameworks and technological innovation evolve at different speeds (14, 19).

Human-Centered Service Practices

Another theme that emerged from the analysis relates to the role of personalized communication and customer assistance in service delivery. Informants described practices such as structured communication methods and educational interactions with users.

These practices appear to play an important role in facilitating communication and supporting user understanding, particularly for patients who may require additional assistance in navigating healthcare services. Interview data indicate that communication with users is organized through a structured workflow rather than handled informally by a single individual. Different staff members are responsible for specific functions, such as responding to initial inquiries, providing medication-related information, coordinating consultations, and managing order processing or delivery arrangements. In practice, messaging platforms such as WhatsApp function as a coordination channel that connects several operational roles within the organization. Incoming requests are first screened and categorized, after which they are directed to relevant personnel, including pharmacists, customer service staff, or operational teams, depending on the nature of the request. This division of responsibilities helps maintain response efficiency and service quality, particularly when handling multiple types of requests such as consultation, education, and payment coordination.

From an operational perspective, this workflow illustrates how digital health services can integrate communication, consultation, and logistics within a single communication interface while maintaining internal task specialization. Previous studies on digital health service delivery have also noted that structured communication workflows and role differentiation are important for ensuring efficiency and maintaining service quality in technology-mediated healthcare interactions. Previous studies have shown that interpersonal interaction and communication support in digital health services can contribute to patient engagement and trust, especially in healthcare settings where information asymmetry is high (3, 4, 20).

Service Integration and Strategic Direction

The findings also indicate that HonestDocs has explored multiple forms of service integration, including access to clinical services. Interview data suggest that these services are primarily facilitated through digital communication channels, where users initiate requests online and are subsequently connected to appropriate healthcare providers or partner facilities. Messaging platforms are used to coordinate appointments, provide preliminary information, and assist users in navigating available services.

In this model, the platform functions mainly as an intermediary that links patients with healthcare providers rather than directly delivering clinical treatment. This approach allows service integration to occur through coordination and referral mechanisms supported by digital communication tools (8, 15). Similar intermediary-based service models have been reported in digital health platforms, where online communication channels are used to organize consultations, schedule appointments, and facilitate access to healthcare services (21, 22).

From an analytical perspective, this pattern can be interpreted within the framework of business model innovation and digital platform development, where value creation often occurs through the integration of complementary services rather than a single product offering (7). Global health policy literature also emphasizes the importance of integrated digital health ecosystems that connect information, clinical services, and financing mechanisms to improve system efficiency and accessibility (15).

Organizational Practices and Adaptability

Interview data further suggest that internal organizational practices, including collaborative decision-making and relatively flexible communication structures, are perceived as supporting operational adaptability. Informants emphasized the importance of rapid feedback and cross-functional collaboration in responding to changing operational conditions.

These observations are consistent with studies on agile organizational practices, which highlight the role of decentralized decision-making and adaptive learning in dynamic and uncertain environments (16). Research on digital transformation also indicates that organizational flexibility and learning capacity are important determinants of adaptation in technology-driven industries (23).

However, it should be acknowledged that the present study relies on self-reported data and does not include independent organizational assessments. Therefore, these findings should be interpreted as exploratory insights into perceived organizational practices rather than objective measures of organizational effectiveness.

Interpretation of Findings

Overall, the findings of this study suggest that business model adaptation in this case involves a combination of technological simplification, service integration, and organizational flexibility in response to external constraints. Rather than representing a linear transformation process, adaptation appears to occur incrementally through operational adjustments and strategic responses to changing conditions.

These findings provide qualitative support for existing literature emphasizing the importance of adaptive capability and flexible business model design in digital health startups operating in emerging markets (7, 19). At the same time, the results should be interpreted within the limitations of a single-case qualitative study and should not be generalized to all digital health platforms.

Conclusion

This study explored how a digital health startup adapts its business model in response to technological, regulatory, and operational constraints. The findings suggest that business model adaptation in this case involves the use of relatively simple technological infrastructure, personalized service practices, and flexible operational arrangements. Organizational practices, including collaborative decision-making and responsiveness to external constraints, also appear to play a role in shaping these adaptive strategies.

Rather than representing a definitive model of digital health transformation, the findings provide exploratory insights into how adaptation processes may occur in a resource-constrained and regulated environment. The results should therefore be interpreted cautiously, as this study is based on a single-case qualitative design and relies primarily on managerial perspectives. The absence of data from users, regulators, or external partners also limits the breadth of interpretation and prevents conclusions about service effectiveness or performance outcomes.

Despite these limitations, the study contributes to the literature by providing qualitative evidence on the organizational and operational processes underlying business model adaptation in a digital health startup context. The findings may serve as a reference point for future studies that seek to examine digital health platforms using comparative designs, larger samples, or mixed-methods approaches in order to strengthen generalizability.

In practical terms, the study suggests that accessibility considerations, flexible operational arrangements, and the integration of multiple service components may be relevant factors in the development of digital health services in emerging markets. However, these observations should be understood as context-specific rather than universally applicable, and further empirical research is required to validate these patterns in different organizational and regulatory settings.

Future research is recommended to include multiple case studies, perspectives from service users and regulators, and quantitative indicators of performance or service outcomes. Such approaches would provide a more comprehensive understanding of the long-term sustainability and impact of digital health business models.