Access to health care on a global scale remains more a promise than a reality. Although international human rights frameworks affirm that everyone is entitled to a standard of living adequate for health and well-being [1], access to health care in high-resource settings vastly differs from access in low-resource settings.

Telemedicine, often viewed as a technology-driven solution, has emerged as a potential tool to expand access to health care beyond geographical limitations. According to the World Health Organization (WHO), telemedicine is defined as “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communications technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and the continuing education of health care workers, with the aim of advancing the health of individuals and communities” [2]. In practice, this means that telemedicine involves the remote communication of medical advice through digital modalities such as synchronous video consultations or asynchronous messaging applications.

Despite this promising nature of telemedicine, its adoption is still challenged by various obstacles [3]. Barriers in high-income settings mostly encompass confidentiality issues [4], privacy and legal concerns [5], resistance to change [6], workflow issues [7], and interoperability challenges [8]. Here, the adoption of telemedicine is often facilitated by existing infrastructure, established health policies, and broad access to technology, as illustrated by the use of telepsychiatry [9].

Barriers in low-resource settings differ from this. Language barriers [10], understanding medical jargon [11], the need to share a single phone [12], unawareness of technology, technically challenged staff, poor design [13], high expectations of users [14], and implementation costs [15] remain key challenges. As a result, health care systems in low-resource settings are often hindered by infrastructural voids, financial restrictions, and sociocultural resistance.

The literature identifies these contextual barriers but lacks theory-driven insights into how innovation characteristics support adoption of telemedicine in low-resource settings. In particular, the mechanisms through which factors such as affordability, simplicity, adaptability, and cultural fit influence telemedicine adoption remain underexplored [16].

Addressing this gap is essential to position telemedicine as a meaningful solution for health care access.

Frugal innovation, with its emphasis on context-sensitive and resource-efficient solutions, provides a promising lens for this purpose. According to Bhatti et al. [17], frugal innovation is defined as “innovation under constraints” and as a conceptual model with a wide range of perspectives, including “market affordability constraints,” “resource constraints or scarcity,” and “institutional voids or complexities.”

Existing research on frugal innovation, outside the scope of telemedicine, has revealed intricate findings which could offer insights for the adoption of telemedicine. For instance, the more complex an innovation or the setting in which it is introduced becomes, the less likely it is to be successfully adopted [18-21]. This may provide a hint as to how complexity reduction, as a core aspect of frugal innovation, could offer solutions in the interest of adoption, especially for advanced technology concepts such as telemedicine [22].

Specifically for telemedicine, few researchers, such as Li et al. [23], demonstrate how frugal approaches can effectively enhance telemedicine and broaden health care access for underprivileged populations in low-resource settings by using technology affordances in case studies such as free telemedicine camps. These “camps” use frugal innovation in mobile health units such as “Hospitals on Wheels.” The research by Li et al. [23] reveals that patient satisfaction is influenced by aligning the “media richness” of telemedicine with factors such as diagnostic complexity and health care needs, emphasizing how effectively implemented frugal solutions can address diverse medical requirements in a cost-efficient manner. This indicates that the reduction of technological complexity, in combination with a socially oriented health care need, improves adoption and access in favor of telemedicine.

However, a systematic evidence base on how frugal innovation characteristics influence telemedicine adoption in low-resource settings remains missing. Therefore, our study will investigate the following question: How do frugal innovation characteristics contribute to the adoption of telemedicine solutions in low-resource settings?

Accordingly, we will adopt a sociotechnical and multiactor systems perspective in this study. Specifically, we aim to synthesize evidence of case studies in diverse low-resource contexts to assess how frugal innovation characteristics, such as affordability, accessibility, or simplicity, interact with telemedicine technologies. While this contributes to the conceptualization of frugal telemedicine, our review will further examine which frugal innovation characteristics will lead to the adoption of telemedicine and how they do so by exploring the environmental, technological, and system-level factors shaping the adoption process. Where available, our study will further identify relevant variables that may support advanced analytical approaches, such as latent class analysis, to deepen understanding of adoption patterns in resource-constrained health care settings.

While telemedicine and frugal innovation have both been widely studied, the intersection between these concepts, specifically in relation to adoption in low-resource settings, remains underexplored. Existing studies vaguely outline which functions and features frugal innovation principles support and how this translates into adoption and use. We argue that most articles discuss the concept of adoption but most likely mean adoption potential rather than actual adoption. Understanding the contribution of frugal innovation between adoption potential and actual adoption of telemedicine solutions in low-resource settings remains pending.

We aim to synthesize and critically evaluate the existing literature on telemedicine and frugal innovation in the context of adoption in low-resource settings. We hereby focus on qualitative data. The primary research question (RQ) guiding our review is as follows:

The following subresearch questions will help to address the primary RQ:

Our review follows a structured process in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Details of the PRISMA checklist are provided in Checklist 1.

First, we will perform a database search using the concepts of telemedicine and frugal innovation from the literature.

Second, the screening process will encompass three stages: (1) initial screening, (2) full-text screening, and (3) final inclusion decision in the systematic review.

Third, data will be extracted from all eligible records, including characteristics of frugal innovation, functions of telemedicine, and features of telemedicine. Inclusion and exclusion criteria have been identified, guided by the Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) framework.

Fourth, the methodological quality will be assessed via the Mixed Methods Appraisal Tool (MMAT).

Fifth, data synthesis will be conducted using a narrative synthesis approach.

Following the PRISMA guidelines [32], we will perform a systematic search across the following databases: MEDLINE ALL, Embase, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, CINAHL, PsycInfo, Scopus, Dimensions, IEEE Xplore Digital Library, EconLit, the International HTA Database, LILACS (Latin American and Caribbean Literature on Health Sciences), WHO Global Index Medicus, and the WHO Global Health Observatory.

To sufficiently answer the RQs, our search strategy encompasses key concepts through a series of Boolean operators (“AND” and “OR”), related to telemedicine and frugal innovation. To ensure relevant studies are not missed, adoption as a terminology is excluded from the search string. Instead, each study will be manually assessed for its relevance to adoption. The search will be conducted without the application of date or geographic restrictions or limitations on peer-reviewed literature only. Study types will include empirical studies, PhD theses, gray literature, unindexed material, quality control studies, single case studies, multisite studies about telemedicine according to the telemedicine definition, and book chapters. Publication types will be filtered during screening to ensure relevance. The entire search strategy, being developed by an information specialist (CN) in cooperation with the lead author (CA), can be accessed in Multimedia Appendix 1.

Screening will encompass a multistage process, involving (1) initial screening of titles, abstracts, and keywords; (2) full-text review for eligibility; and (3) final inclusion decision for the systematic review. Two independent researchers will perform a blinded screening to evaluate subject relevance for telemedicine and frugal innovation, with a third reviewer resolving conflicts. Full-text screening will be conducted by multiple researchers, with conflicts resolved through regular alignment and consensus meetings.

Data will be extracted from all records eligible based on characteristics of frugal innovation, functions of telemedicine, and features of telemedicine. Reviewer disagreements will be resolved through discussions, with consensus documented in the final data extraction table in Microsoft Excel. An assessment of adoption will be performed by interpretation by the researchers. Data will be extracted and managed using Covidence (Veritas Health Innovation Ltd), documented in a data extraction table. Table 1 outlines the data items to extract in accordance with the RQs.

Our inclusion and exclusion criteria for selected studies will be guided by the SPIDER framework, considering sample, phenomenon of interest, design, evaluation, and research type [33]. We will include case studies that have been implemented in low-resource settings, incorporating the concepts of telemedicine and frugal innovation.

Inclusion criteria can be found in Table 2.

Exclusion criteria can be found in Table 3.

We will assess the methodological quality of the included studies using the appropriate critical appraisal tools provided by MMAT [34]. This tool is specifically designed to assess the methodological quality of case studies included in systematic reviews, incorporating various study designs. The selection of the MMAT assessment will be based on the study design of each included study. Quality assessments will be conducted independently by 2 reviewers. Discrepancies will be resolved through consultation with a third reviewer.

A narrative synthesis will ensure accessibility for nonexpert audiences by avoiding jargon, explaining terms as needed, and adhering to open-access standards. This narrative will be aligned with the RQs to ensure a clear connection between the synthesis and the overarching goals of the review. To ensure the accuracy and quality of translations, we will implement a standardized translation protocol.

Ethics approval is not required, as this study does not involve the collection of primary or clinical data. Review findings will be shared via peer-reviewed journal publications, conferences, stakeholder meetings, and online presentations.

In our review, we aim to explore how frugal innovation characteristics contribute to the adoption of telemedicine solutions in low-resource settings. While we understand this task as a contribution to conceptualizing frugal telemedicine, we also aim to focus on the perspective of how innovation characteristics can lead to better adoption. Here, we argue that adoption may not be considered a discrete, binary event but rather a processual perception among individuals and groups across different levels (i.e., individual, organizational, and system levels).

Although frugal innovation is frequently presented as a promising complement to telemedicine in resource-constrained settings, its role in adoption remains insufficiently theorized. Specifically, it is necessary to critically reflect on for whom, under what conditions, and at which levels frugal innovation characteristics support telemedicine adoption. Therefore, this review aims to move beyond descriptive adoption barriers and facilitators by examining the underlying mechanisms and contextual requirements through which frugal innovation characteristics may influence adoption in low-resource settings.

The findings are expected to inform future empirical research, supporting more context-sensitive approaches to the design and adoption of telemedicine interventions in low-resource settings.

Our review is not intended to generate causal claims but rather to clarify patterns, mechanisms, and knowledge gaps regarding the adoption of telemedicine in low-resource settings. The interdisciplinary nature of our study will likely result in heterogeneous findings, which may limit the identification of operationalizable and measurable outcomes. Consequently, a narrative synthesis is proposed, where findings will be interpreted in a context-sensitive manner. Relevant studies may not explicitly identify interventions as frugal innovation, which can introduce an interpretive element. We aim to mitigate this limitation through a comprehensive search strategy, using a wide range of relevant search terms, as well as independent screening and consensus-based alignment procedures.

Telemedicine adoption and frugal innovation require sensitivity from a sociocultural and technical standpoint. However, inconsistent reporting of these dimensions across studies may constrain the depth and interpretability of our synthesis. The review may also be subject to publication and language bias, as studies reporting unsuccessful or negative adoption experiences may be underrepresented.