Mobile phones: you see them being used in airports, at the grocery store, on subways and buses, and even in the hand of your doctor. In fact, it is difficult to go anywhere these days without seeing someone use a mobile phone. That should not be surprising considering that, according to the International Telecommunications Union (ITU) of the United Nations, there were almost six billion mobile phone subscriptions by the end of 2011 – the same year the world’s population hit seven billion.
The ubiquity of mobile phones has not gone unnoticed by development and global health experts. These experts, along with entrepreneurs and innovators, have formed a movement – commonly known as mobile health or mHealth – to harness the potential of mobiles to improve health outcomes.
mHealth can be defined as medical and public health practices supported by mobile technologies, such as mobile phones, patient monitoring devices, tablets, personal digital assistants (PDAs), and other wireless devices. Patients, providers, health administrators, and public health advocates can all use mHealth to strengthen health systems by improving health services and expanding their reach.
There are several opportunities for mHealth to transform healthcare systems, particularly in developing countries, where public health information and access to health services are severely limited by the lack of facilities, trained personnel, and supplies. First, mHealth can create critical efficiencies in health delivery – be it through accessing electronic health records or remote monitoring of patients. Second, mHealth enables access to health information and services in remote and resource-poor settings.
mHealth in developing countries
Last year, the ITU estimated that almost 75 percent of mobile subscriptions were in developing countries, a figure that far exceeded fixed phone line subscriptions and internet users. Healthcare costs are rising worldwide while both communicable and noncommunicable diseases (NCDs) are growing concerns for health ministries. According to the World Health Organization’s Global Status Report on Noncommunicable Diseases that was released earlier this year, of the 57 million global deaths in 2008, NCDs were responsible for 36 million (63 percent). These deaths were primarily the result of cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases. While it is popularly believed that NCDs are most common in high-income countries, 90 percent of NCD deaths occur in low- and middle-income countries.
Developing countries are hit hardest because while NCD rates are increasing, the rate of infectious diseases, such as HIV/AIDS and malaria, remain high. This problem is exacerbated by the fact that in these countries, public health and access to health services is limited by lack of facilities, trained personnel, and supplies, among other health systems challenges.
We are fortunate that a solution rests literally in the hands of the majority of the world’s population.
The World Health Organization’s (WHO) 2009 Global Observatory for eHealth (electronic health) conducted a survey on mHealth and found that, of the 114 countries that participated, 83 percent reported at least one mHealth initiative in their country. Beyond that, of the countries that reported at least one mHealth initiative taking place, 83 percent of those reported four or more mHealth initiatives. Although a relatively new strategy in medicine, mHealth is quickly gaining traction throughout the world.
Programmes have been most successful and influential in developing countries. This may be due to the lack of infrastructure and health workers, increased rates of infectious diseases, and high rates of mobile phone use.
The role of mHealth
The flexibility of mHealth has afforded it a wide and growing range of innovative applications. For example, mHealth can be used for education and awareness through text messaging that supports broader public health and behavioral change campaigns. It is a useful tool for diagnostic and treatment support, as mobile phones can guide the decisions of healthcare providers and serve as point-of-care support tools.
|A Bangladeshi mother living in the Dhaka slums uses the Mobile Alliance for Maternal Action programme for information on childcare [Mobile Alliance for Maternal Action/Solutions Journal]|
Mobile phones can also send and receive data on disease incidence and public health emergencies, which helps to track disease and epidemic outbreaks. Mobile tools can manage supply chains by monitoring stock levels and combating the distribution and sale of counterfeit pharmaceuticals. Real-time patient data can also be collected remotely with mobile applications. Finally, mobile devices can train health workers and improve health worker communication of and access to information.
Most immediately, mHealth provides education and awareness through interactive public health messages, often targeted toward individuals at risk for certain health conditions. The Mobile Alliance for Maternal Action (MAMA) is a perfect example. This public-private partnership between Johnson & Johnson and USAID, with the support of the United Nations Foundation, mHealth Alliance, and BabyCenter, provides health information to expectant and new mothers who, along with their children, are at risk for complications and death during pregnancy and childbirth.
The messages are developed around “age and stage”, meaning they follow the expectant mother’s pregnancy and provide her and her family with messages that are appropriate for that particular point in the pregnancy, as well as the baby’s first year of life.
MAMA is doing this by creating and strengthening programmes in three countries – Bangladesh, South Africa and India – which were selected based on their high maternal mortality rates and high rates of mobile phone usage. MAMA Bangladesh will launch nationally this year, and the country programmes in both South Africa and India are underway.
The messages used by MAMA are adaptable and allow for cultural and linguistic sensitivities. To accommodate the potential barrier of illiteracy, the messages are delivered either as a text message or an audio recording. Where dialects are strong, the messages can be re-written or re-recorded to ensure the information is delivered in its most easily understood form.
MAMA has also opened its entire messaging library so that other organizations can replicate the initiative and improve health for mothers and their babies in other areas. Through the adaptive messaging programme, MAMA’s vital and culturally sensitive health messages are now reaching new and expectant mothers in 35 countries, from Afghanistan to Zambia, with a projected reach of over 20 million moms.
In terms of diagnostic and treatment support, mobile phones can collapse geography and link medical experts with health workers to create virtual healthcare teams for the management of specific cases. For example, in Tanzania, D-Tree International is using mobile phones to help promote proper child healthcare and reduce the number of children – estimated at 10 million worldwide – who die each year from preventable or treatable causes.
The WHO’s Integrated Management of Childhood Illness (IMCI) protocol sets standards for classifying and treating common causes of death, such as pneumonia, diarrhea, malaria, measles, and malnutrition. D-Tree’s programme has improved the flexibility and use of IMCI protocols by making them available on mobile phones and other devices.
Adhering to the protocols
The results of early testing of this system have shown that health workers more closely adhere to the protocols when using the mobile-enabled system. In fact, all of the clinicians who participated in the initial pilot preferred using the application because it is faster and easier to use than a reference book.
The ability of mobile phones to collect and send data quickly and cost-effectively makes them extremely effective for tracking epidemics and outbreaks. Phones can be used to determine the location and level of certain diseases, such as HIV/AIDS, tuberculosis and malaria. This information can then be sent to ministries of health and other organisations where an outbreak is occurring, so they can respond accordingly with the appropriate counter-measures.
Partners in Health has recently employed mobile epidemic outbreak tracking in Haiti, where cases of cholera since the 2010 earthquake have continued to devastate homeless and migratory populations. Community health workers are using mobile phones to submit cholera reports from the areas in which they work. Prior to the integration of this mobile technology, the workers had to travel long distances to submit reports, often walking more than six hours weekly.
In this instance, mHealth saves time and provides up-to-date information for better disease tracking and response. Similar projects that track other outbreaks have been deployed throughout the world, including a project in Cambodia that uses FrontlineSMS, an open-source software platform, to allow volunteers to track malaria.
In Tanzania, supply chain management is crucial when it comes to fighting diseases with short onset times. In the case of malaria, the first 18 to 24 hours are critical as drugs must be administered within this timeframe. In many areas, however, medication stocks at health clinics can dwindle to nothing, leaving malaria patients without access to potentially life-saving treatments. Furthermore, there is often not any way to know if other clinics in the area have the drugs available.
A programme called SMS for Life uses mobile technologies to improve access to medicines essential to the treatment of malaria and other diseases in rural parts of sub-Saharan Africa. SMS for Life, a public-private partnership led by Novartis, provides incentives to community health workers to use SMS to submit their stock levels of medicines on a weekly basis.
The system works by sending a weekly SMS message to a registered user at each health facility asking what their current stock levels of medications are. The data is then sent to a secure website that enables the district medical officer to determine whether anti-malarial drugs need to be transferred between facilities or reordered.
The pilot study for this programme found that the proportion of health facilities with no stock of anti-malarial medicine fell from 78 percent in the first week to 26 percent in week 21. The goal of this programme is to eliminate stock-outs, increase access to essential medicines, and therefore reduce the number of deaths caused by malaria.
However, having access to medicines is not always the problem. According to the WHO, the number of counterfeit medicines is on the rise, and the problem is particularly acute in developing countries. In parts of Asia, Latin America and Africa, more than 30 percent of medicines in circulation are counterfeit.
The global profusion of mobile phones is becoming a powerful healthcare tool for rural health clinics [Kelly Ramundo/USAID]
Protecting supply chains
Protecting supply chains and people from counterfeit medicines is the mission of the Ghanaian non-profit mPedigree. This organisation collaborates with telecommunication operators, the pharmaceutical industry and technology companies to provide patients and consumers with a verification system through which they can text in serial codes. If the number has been registered, they will receive confirmation that the medicine is authentic; if, on the other hand, the number is unregistered, then they receive a warning about its inauthenticity.
This programme is currently helping people receive appropriate treatment for their illnesses in Ghana, Rwanda, India and the Philippines. mPedigree has particularly taken root in Ghana, where the Food & Drug Board, the Ghana National Drug Program, and the Ghanaian Ministry of Health have been very involved in the project since its inception.
As mentioned in the examples from Tanzania and Haiti, data collection is another area in which mobile technology can be used to strengthen health systems. EpiSurveyor, an open source mobile data collection platform, provides basic data collection services free of charge. EpiSurveyor has been used across development sectors and is frequently used in mHealth programmes.
For example, this technology was used by USAID and ABT Associates in Nigeria to monitor supplies, and to track patient load, positivity rates, and treatment success rates for tuberculosis. Management Sciences for Health has also used the programme to strengthen pharmaceutical systems in Malawi by reducing costs and improving the accuracy of the data collected.
EpiSurveyor epitomises the idea that mobile phones can be used decrease operating costs. In fact, a 2011 World Bank report documented a 71 percent decrease in data collection costs compared to paper. This tool has been used in more than 170 countries by over 9,500 users, from the International Federation of the Red Cross to the World Health Organization.
Lastly, mHealth can be used to improve communication between doctors, thereby improving medical training and education. Switchboard for example, a non-profit based in San Francisco, has developed a system by which health professionals can communicate on their mobile phones for free.
It also provides doctors with a directory of medical workers to expand their support network. Almost every doctor in Ghana and Liberia has been included in the Switchboard network, and the programme has recently expanded to Tanzania where Switchboard worked with Vodacom to connect 9,000 health workers.
This network has improved care by enabling isolated, rural health workers to immediately access information from providers and organizations in urban areas. This increased communication and support is particularly valuable in these countries, where the health worker shortage is severe and one health worker with limited training may need to care for 5,000 to 150,000 patients.
The programme presents a possible remedy to the isolation experienced by rural doctors and can improve the knowledge and skills of frontline health workers, nurses, doctors and other health professionals.
The challenge of advancing mHealth
The mHealth field continues to progress, as demonstrated by these applications and countless other unmentioned, innovative models for efficiently improving health outcomes. Despite these advancements, several persistent shortfalls constrain the full potential of mHealth. These include lack of rigorous evidence, limited technological integration and interoperability, limited sources of sustained financing, policy gaps and lack of capacity among those who could benefit most from using mHealth.
Moving beyond the pilot stage of mHealth will first require a more solid foundation of evidence. To build this, we simply need more research.
The majority of mHealth reports focus on describing applications and programmes, rather than on documenting their impact on health outcomes. Thus far, most of the evidence base comprises case studies that are not replicable and do not have large sample sizes. Without solid evidence to support its implementation, it will be difficult to successfully bring mHealth to scale.
A recent study revealed that there is a large quantity of evidence on the impact of mHealth, but it is of low quality and fails to address key issues, such as clinical outcome, cost comparison, and wider health system benefits. This renders the evidence ineffective in building the case for mHealth. Higher-quality evidence is required to inform funders, policy makers, health workers, and other key players about the growing availability and importance of mHealth. Research needs to be rigorous, high quality and ultimately link mHealth implementation to improved health outcomes.
A repository of research, lessons learned, tools and open-source resources on the subject of mHealth would benefit both those who have been working in the field for some time and newcomers. It could provide information about the current state of mHealth and help practitioners avoid common mistakes when initiating a new programme.
Interoperability is the ability of health information systems to work together within and across organisations to advance the effective delivery of healthcare. mHealth programmes often develop independently of each other, and there has been surprisingly little collaboration across programmes. These independent systems have developed largely without donor or government guidance on best practices or standards.
Without standards, programmes and devices cannot easily communicate with each other and information is not easily transferred from one system to another – a failure of interoperability. This lack of standards has also limited mHealth’s ability to work with other established mServices, like mobile banking and mobile education.
|Using the mPedigree Network, pharmacists are able to verify the serial number of medication using their mobile phone to detect counterfeits [mPedigree Network/Solutions Journal]|
To combat this fragmentation, it is essential for the mHealth community to develop a joint set of services, frameworks and standards. Though individual mHealth projects have not traditionally had a platform to facilitate this collaboration, there are now opportunities to share lessons learned and new ideas through platforms like healthunbound.org (HUB), an interactive network and online knowledge resource center for the mHealth community. A neutral space for developers, health experts and entrepreneurs to come together is critical to developing programmatic methods that can benefit the mHealth ecosystem.
Sustainable finance models
Overall, there is limited funding going into mHealth, particularly compared to general funding for global health: global health funding in 2010 reached close to $27bn, but mHealth received only $30m of this. Furthermore, the existing funding is focused primarily on research, development, and piloting rather than on intervention through large-scale projects. Sustainable business models are needed to ensure mHealth programmes have a valuable and long-term impact on the people they serve.
Communication between mHealth programmes and other mService platforms would greatly amplify the pace of mHealth integration and strengthen health systems. In countries like Kenya, we have begun to see how mHealth can harness the power of the established mobile money market to assist with medical payments.
The organisation Changamka is using the already robust mobile network to enable clients to save on smart cards through M-PESA, a mobile money system, and make healthcare payments using this card at designated providers. This system is creating mechanisms for the delivery of affordable healthcare for millions of Kenyans who were previously excluded from government arrangements and private insurance schemes.
However, Changamka is just one solution to the many obstacles impeding mHealth funding. Another solution is partnerships, especially public-private partnerships, which draw strategic resources (through both funding and in-kind expertise) from various mHealth stakeholders.
For example, the newly launched mPowering Frontline Health Workers brings together 11 founding partners to improve child health by accelerating the use of mobile technology by millions of health workers throughout the world. Partnerships like this one and MAMA, discussed earlier, are leading the way, but more work needs to be done.
A recent WHO report named gaps in knowledge and policy as the top reason why mHealth has not been implemented more widely. In particular, lack of national policies that support the use and mainstreaming of mHealth into the health system inhibits mHealth growth. Additionally, when countries have national eHealth policies, as Bangladesh does, mHealth programmes are not always aligned with those priorities. Understanding and drawing attention to these gaps in policy is a necessary step to the effective scaling of mHealth projects.
One way to address this issue would be to build more interactions and knowledge sharing between governments that have implemented mHealth policies and those that are just beginning. This could be accomplished by cataloguing information on the effective use of mHealth, advocating for its use, and disseminating this information in regional workshops, reports, or online.
The majority of stakeholders throughout the field – including funders, telecommunications providers and health workers – lack a full understanding of how to use mHealth effectively. This inhibits the widespread uptake of mHealth solutions and can even have a negative impact on pilot projects by inhibiting their progress.
The challenges associated with capacity include a lack of cross-sector understanding of global health and mobile technology and limited tools for training and accreditation in the design and use of mHealth among health workers and administrators. Additionally, after mHealth programmes are designed and implemented, there is often a low level of health and technology literacy among end-users. All of this contributes to limited evidence on the costs and benefits needed to inform policy and funder decisions.
To address these capacity shortfalls, workshops are being conducted and tools created to assist with training and implementation. For example, HUB provides an online knowledge resource center and interactive network for the mHealth community. It creates connections between those interested in using mobile devices and technologies to improve the health of people in low- and middle-income countries.
Members include health practitioners, mHealth implementers, government leaders, NGOs, donors, international organizations, corporations, academics and researchers, and the people they serve. HUB hosts a variety of tools and an interactive database of almost 850 mHealth programmes, technologies, organisations and policies. On HUB, users can learn about the latest research and reports and read perspectives from leaders in the field through blogs.
But this is just the beginning. The capacity of users, both health professionals and patients, must be taken into consideration throughout the programme design process. Further work is needed in this area, as well as on other issues like accreditation, end-user technology literacy and cost-benefit analyses.
We believe that mHealth has tremendous potential to improve health outcomes in developing countries. But, despite a global surge in programmes and initiatives, it is not yet living up to its potential. What is needed, more than piecemeal investment and strategy, is strong evidence to develop policy, and forward-thinking policy to build scale and capacity. Sustainable business models are required for long-term mHealth initiatives, as are the interoperability of programmes and devices and the integration of technology into existing healthcare systems.
Building reliable evidence is essential to all areas of growth, but rigorous and high-quality research will take time. Even so, progress can be made in other areas. The mHealth community is a dynamic group of stakeholders, from mobile network operators to community health workers to global health experts. And they are all, together, leading the shift toward a world where the power of health communication and information is at everyone’s fingertips.
Patricia Mechael is the executive director of the mHealth Alliance, which is hosted by the United Nations Foundation, and faculty at the School of International and Public Affairs and Earth Institute, Columbia University. She has been actively involved in the field of international health for 15 years with field experience in over 30 countries primarily in Africa, the Middle East, and Asia.
Sarah Struble is a programme associate at the mHealth Alliance. Prior to joining the mHealth Alliance, she was a United Nations Foundation intern. Her work at the mHealth Alliance focuses on research, policy, communications, and strategic partnerships. Her interest in global health began while studying abroad in Botswana and working at a day care center for orphans and vulnerable children.
A version of this article first appeared on Solutions Journal.