MobileActive.org

The use of mobile phones to improve the quality of care and enhance efficiency of service delivery within healthcare systems is known as mobile health, or mHealth, and is a sub-segment of the broader field of electronic health (eHealth). WHO has defined mHealth as the “provision of health services and information via mobile technologies such as mobile phones and Personal Digital Assistants (PDAs).” mHealth tools have shown promise in providing greater access to healthcare to populations in developing countries, as well as creating cost efficiencies and improving the capacity of health systems to provide quality healthcare. 

Recent evidence from randomized scientific trials and studies has demonstrated that the capabilities of mobile phone technology, particularly SMS messaging, can positively impact treatment outcomes. Results of the WelTel Kenya1 clinical trial, the first study of its kind in Africa, were published in The Lancet in November of 2010. The trial focused on the impact of SMS messaging on HIV-infected adults starting antiretroviral therapy (ART) in three clinics in Kenya. The study showed that patients who received SMS support had significantly higher adherence to ART and higher rates of viral suppression when compared with patients in the control group. A scale up of such a mobile phone support system in Kenya could suppress viral loads in 26,000 extra people at the cost of less than USD 8 per person per year, according to Richard Lester of the British Columbia Centre for Disease Control and the study’s lead researcher. Another cluster-randomized trial at 107 rural facilities in Kenya found that SMS message reminders sent to health workers’ mobile phones improved and maintained their adherence to treatment guidelines for outpatient pediatric malaria in Kenya.

A multitude of mHealth solutions have emerged over the years in countries such as Ethiopia, Kenya, Nigeria and South Africa, which are leading the way in using mobile health services, according to the Global Observatory for eHealth at the WHO. Getachew Sahlu of the WHO identified the convergence of the following factors as the driving force behind the current rapid mHealth growth in developing countries: (1) a record growth of mobile phone users, (2) rapid expansion of mobile networks, (3) the decline in mobile phone costs, and (4) the innovation in mobile technology. The mobile platform presents the unique capability of delivering healthcare services wherever people are—not just in healthcare facilities. mHealth initiatives have also been effective in reaching underserved populations, particularly those in rural areas, changing health behaviors and outcomes, and addressing a wide variety of healthcare challenges, including:

• The shortage of skilled healthcare workers in certain developing country settings
• Treatment adherence and compliance
• Lack of timely and actionable disease surveillance
• Poor drug inventory and supply chain management
• Use of counterfeit drugs
• Lack of medical diagnostic treatment
• Slow rates of information flow and reporting delays.

mHealth represents a cost-effective technology solution to many of these challenges if implemented correctly and brought to scale. The costs of mobile handsets and usage are declining as demand for mobile services increases and mobile networks are being rapidly expanded.

Around the world, countless lives are lost due to insufficient access to quality health information. The availability of accurate, timely, and analyzed data is directly relevant to the quality of an individual’s health and the healthcare system in general, the delivery of individual care, and the understanding and management of overall health systems.

This discussion paper:

1) Examines the role ICTs, and mobile technology in particular, can play in improving access to quality health information, review the ecosystem of health information related to patients,

2) Traces the data throughout the continuum of care, examine health information flows from patients in villages to international health organizations and the most important steps in between,

3) Identifies common ground on which technologists and public health professionals can develop innovative strategies and tools to strengthen health care systems by supporting health data flows, working from the premise that better data collection will lead to better health policies and health outcomes,

4) Focuses on three healthcare domains – surveillance systems, supply chain, and human resources – and through the perspectives of experts in these domains, identify critical gaps in health information flows that technology-based solutions could address. In the case of each of these three domains, we use maternal health as an example to show how technology-backed interventions can improve health information flows,

5) Identifies barriers, choke points, and other inefficiencies to guide the discussion of how modern ICTs can improve health information flows and health outcomes in the developing world,

6) Provides recommendations for using modern ICTs to make health information flow more efficiently and perhaps even transform the process of care delivery itself.

The Vodafone Health Debate series is part of our continuing commitment to thought leadership in healthcare. It brings together senior pharma, public and private health stakeholders to learn, share and debate on issues and new thinking brought forward by renowned thought leaders and industry experts. Our aim is to provide some evidence- based stimulus that will encourage all those working in the different areas of healthcare to consider the innovation opportunities that are now available to them.

We believe that real progress can only be initiated when all stakeholders look beyond traditional horizons and share ideas that challenge the status quo so that together we can identify new ways of addressing current issues. Regulatory complexity, financial constraints, entrenched infrastructures and poor investment in technology combined with a lack of understanding by technology providers has meant that digital innovation in healthcare has been slow to take hold.

However, given changing healthcare needs of an increasingly aging population and the challenges presented by the current economic crisis, there is renewed interest in the potential of mHealth and Internet solutions to help reduce costs, increase efficiencies and effectiveness. This paper explores the practical reasons behind the slower than expected adoption of digital health technologies and discusses experiences from other sectors that could potentially help create wide scale adoption.

Stock-outs of malaria treatments at the health facility level in many sub-Saharan African countries have been a persistent problem for many years. A stock-out is the unavailability of medicine at the health facility. In Tanzania, 93 % of the population are at risk for malaria infection. The number of malaria cases is estimated to be 11 million resulting into 60-80 thousand deaths per year or 220 deaths per day in Tanzania alone. The goal of the SMS for Life pilot project was to develop a flexible and scalable solution to bring up-to-date visibility of anti-malarials within the Tanzanian Public Health Sector with a potential to reduce or eliminate stock-outs of five drugs (four dosage forms of ACTs and Quinine Injectable) in all health facilities in a pilot sample of three districts.

Initiated and led by Novartis, a public-private partnership was established with the Roll Back Malaria Partnership, IBM, Vodafone and the Ministry of Health in Tanzania. This unique partnership developed a solution using mobile phones, SMS messages, internet and mapping technology to visualize weekly stock inventory of Artemisinin Combination Therapy (ACTs) and Quinine Injectable at 129 health facilities and 226 villages. Over the course of one year, the Project Team designed the system, created a data repository, trained key staff and implemented the solution for a 21-week pilot in three districts of Tanzania: Ulanga, Kigoma Rural and Lindi Rural. These districts are located in three different regions and supplied from different Zonal Stores with a catchment population of 1.2 million people.

We explore the potential of using camera phones and pico projectors in rapid creation and presentation of digital content in a development context. A camera phone based content authoring application was designed and deployed with three different user populations in the domains of classroom education and health care.

Our findings show that despite the variations in education levels, cultural background, and technology exposure, users successfully created and presented different forms of digital content using the camera phone and pico projector.

The application of mobile computing and communication technology is rapidly expanding in the fields of health care and public health. This systematic review will summarise the evidence for the effectiveness of mobile technology interventions for improving health and health service outcomes (M-Health) around the world.

To be included in the review interventions must aim to improve or promote health or health service use and quality, employing any mobile computing and communication technology. This includes:

(1) interventions designed to improve diagnosis, investigation, treatment, monitoring and management of disease;

(2) interventions to deliver treatment or disease management programmes to patients, health promotion interventions, andinterventions designed to improve treatment compliance; and

(3) interventions to improve health care processes e.g. appointment attendance, result notification, vaccination reminders.

A comprehensive, electronic search strategy will be used to identify controlled studies, published since 1990, and indexed in MEDLINE, EMBASE, PsycINFO, Global Health, Web of Science, the Cochrane Library, or the UK NHSHealth Technology Assessment database. The search strategy will include terms (and synonyms) for the following mobile electronic devices (MEDs) and a range of compatible media: mobile phone; personal digital assistant (PDA); handheld computer (e.g. tablet PC); PDA phone (e.g. BlackBerry, Palm Pilot); Smartphone; enterprise digital assistant; portable media player (i.e. MP3 or MP4 player); handheld video game console. No terms for health or health service outcomes will be included, to ensure that all applications of mobile technology in public health and healthservices are identified.

Bibliographies of primary studies and review articles meeting the inclusion criteria will besearched manually to identify further eligible studies. Data on objective and self-reported outcomes and study quality will be independently extracted by two review authors. Where there are sufficient numbers of similar interventions, we will calculate and report pooled risk ratios or standardised mean differences using meta-analysis.

This systematic review will provide recommendations on the use of mobile computing and communication technology in health care and public health and will guide future work on intervention development and primary research in this field.

‘Aarogyam’ is a Sanskrit word which means "complete freedom from illness”. Aarogyam is an ICT based responsive system which ensures and involves active participation of all key stakeholders viz. local administration, health facilities and doctors, frontline health workers (ASHA (Accredited Social Health Activists), ANM (Auxiliary Nurse Midwife), and AWW (Angan Wadi Workers)), village heads and beneficiaries, to ensure that a pregnant woman is provided with ANC, PNC and complete immunization throughout the continuum of care.   Aarogyam maintains a village wise database of all the beneficiaries (pregnant/lactating women, children up to 5 years) of an area, which gets continually updated with new data generating on the field with the help of front line health workers. The database thus generated is the backbone of the software system used by Aarogyam. This system generates automated alerts in the form of vernacular voice calls/SMS to the beneficiary thus enabling the beneficiary with vital information at their door step.   The system not only provides beneficiary with the information to be acted upon but also ensures that the services are delivered to the beneficiary by generating automated alerts (vernacular voice calls/SMS) for the ANM and Block level health officials, informing them of due services in their area.  

At the UN Millennium Summit in September 2000, world leaders adopted the Millennium Declaration, committing nations to a new global partnership to reduce extreme poverty and address pressing challenges of hunger, gender inequality, illiteracy, and disease. The year 2015 has been affirmed as the deadline for reaching these Millennium Development Goal (MDG) targets.

The goal is to show how an integrated approach to community-level development can translate the international MDG agreements into ground-level breakthroughs throughout rural sub-Saharan Africa. Villages are located in deeply impoverished rural areas that were considered hunger hotspots—with at least 20% of children malnourished. Sites were selected to reflect a diversity of agro-ecological zones, representing a range of challenges to income, food production, disease ecology, infrastructure, and health system development.

The Millennium Villages Project is a ten-year initiative spanning two five-year phases. The first phase focuses on achieving quick wins, especially in staple crop production and disease control, and on establishing basic systems for integrated rural development that help communities escape the poverty trap and achieve the MDGs. The Project involves the coordinated community-led delivery of a locally tailored package of scientifically proven interventions for agriculture, education, health, and infrastructure. Over the first five-year phase, interventions are delivered at a modest cost, totaling approximately $120 per capita per year, of which MVP brings about half to complement funds from the host government, the local community, and other partners. The second five-year phase will focus more intensively on commercializing the gains in agriculture and continuing to improve local service delivery systems in a manner that best supports local scale-up.

This report for mHealthEd 2011 at the Mobile Health Summit focuses on the effectiveness of mHealth Education applications, analyzing at length the first wave of projects and the steps to be taken into consideration for further initiatives.

The first wave of mHealthEd applications for health workers – most introduced within the last 4 years and some of which are 7 presented in this report – include ones which enable workers to learn new treatment procedures, test their knowledge after training courses, take certification exams remotely, look up information in medical reference publications, and trade ideas on crucial diagnostic and treatment decisions. It is too early to test for impacts on health outcomes, but projects suggest that mHealthEd applications are improving the provision of care and levels of knowledge. Improved training can also increase job satisfaction and reduce attrition rates for healthcare workers.

While researchers are often depicted as either ‘social scientists’ or ‘technologists’ often their educational and ideological backgrounds are much richer than the two simple terms might imply.

This paper describes the methodology and approach of a qualitative researcher with a computer science background in investigating how information technology changes communications and information management practices within the health ecosystem constitutued by a health subsidy program in southwest Uganda.

While mobile phones have found broad application in reporting health, financial, and environmental data, there has been little study of the possible errors incurred during mobile data collection. This paper provides the first (to our knowledge) quantitative evaluation of data entry accuracy on mobile phones in a resource-poor setting.

Via a study of 13 users in Gujarat, India, we evaluated three user interfaces: 1) electronic forms, containing numeric fields and multiple-choice menus, 2) SMS, where users enter delimited text messages according to printed cue cards, and 3) voice, where users call an operator and dictate the data in real-time. Our results indicate error rates (per datum entered) of 4.2% for electronic forms, 4.5% for SMS, and 0.45% for voice.

These results caused us to migrate our own initiative (a tuberculosis treatment program in rural India) from electronic forms to voice, in order to avoid errors on critical health data. While our study has some limitations, including varied backgrounds and training of participants, it suggests that some care is needed in deploying electronic interfaces in resource-poor settings. Further, it raises the possibility of using voice as a low-tech, high-accuracy, and cost-effective interface for mobile data collection.

This compendium of articles (available at a cost) attempts to critically investigate the use and utility of mobile phones in Africa. Contributors include Nathan Eagle who writes about ‘Economics and power within the African telecommunication industry’,  Amanda Atwood’s report on Kubatana’s experiences in Zimbabwe setting up mobiles as a means of sharing news outside of government propaganda, to Bukeni Waruzi’s essay on collecting data on children’s rights violations in the Democratic Republic of Congo in 2004.  SMS Uprising is published by Fahamu, a British-based organization with a focus on information services for Africa. For a critique of the book see our aticle here.

The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks.

According to the International Telecommunication Union (ITU), there are now over 5 billion wireless subscribers; over 70% of them reside in low- and middleincome countries. The GSM Association reports commercial wireless signals cover over 85% of the world’s population, extending far beyond the reach of the electrical grid.

For the first time the World Health Organization’s (WHO) Global Observatory for eHealth (GOe) has sought to determine the status of mHealth in Member States; its 2009 global survey contained a section specifically devoted to mHealth. Completed by 114 Member States, the survey documented for analysis four aspects of mHealth: adoption of initiatives, types of initiatives, status of evaluation, and barriers to implementation. Fourteen categories of mHealth services were surveyed: health call centres, emergency toll-free telephone services, managing emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, health awareness raising, and decision support systems.

The opportunities in South Africa for using mobile technologies to support initiatives in the HIV/AIDS sector are enormous. A huge number of people have cellphone access, and there are a range of innovative ways in which cellphones can be used to support treatment, disseminate information, provide anonymous counselling, gather data and link patients to services. Cell-Life is an NGO based in Cape Town, South Africa, that seeks to improve the lives of people infected and affected by HIV through the appropriate use of technology. This paper describes three pilot interventions that use cellphones for behaviour change communication, ie that are experimenting with different cellphone technologies to disseminate information, undertaken as part of Cell-Life’s Cellphones4HIV project: ARV adherence SMSs, USSD content delivery and content delivery via MXit. Challenges around measuring impact in behaviour change communications are briefly discussed, and some of Cell-Life’s upcoming initiatives are outlined.

Grameen Foundation’s experience of designing and implementing a mobile health program in Ghana can provide insights for the broader field and specific projects that are in early phases of planning and implementation. A fundamental tenet of Grameen Foundation’s work is to share information broadly, from program designs to management plans to source code to lessons learned - both successes andfailures. To that end, this document is intended to provide:

1) A comprehensive overview of the Mobile Technology for Community Health (MOTECH) project in Ghana and how it works.

2) An insight into strategic decisions and design approaches made by the project team throughout the course of the implementation.

3) Information on lessons learned during the project and implications of decisions on future scale.