mHealth in Africa: challenges and opportunities
Estimated reading time: 8 Minutes
Disseminating healthcare resources and information in countries with a widespread rural population and limited financial resources remains a public health issue. Here, Temitope Folaranmi, MPP alumnus, looks at mHealth as an innovative and potentially effective solution to overcome these problems.
Over the past decade, Africa has experienced an incredible boom in mobile phone use. In 1998, there were fewer than 4 million mobile subscriptions on the continent, but today, there are more than 800 million subscriptions, and this is projected to reach 1.12 billion subscriptions by 2017. (1) Various studies (2)(3) on pilot projects implemented in Africa support the claim that mobile technologies have the potential to transform the face of healthcare by serving as vehicles for delivering specific health interventions. This form of health service delivery, known as mHealth, is seen as a complementary strategy for strengthening health systems and achieving the health-related Millennium Development Goals (MDGs) in low-income countries.
The term mHealth was coined by Professor Robert Istepanian, who described it broadly as the use of ‘emerging mobile communications and network technologies for healthcare’. (4) Essentially, mHealth is the use in medicine and public health of mobile communication devices ‘such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices,’ (5) to ‘enhance access to health information, improve distribution of routine and emergency health services, or provide diagnostic services’. (6)
mHealth platforms operate on the premise that technology integration with the health sector has the potential to improve health outcomes. (7) Today, countries such as Ethiopia, Kenya, Nigeria and South Africa are leading the way in using mHealth solutions for health service delivery, (8) and this is driven by the convergence of a myriad of factors – expanding penetration of mobile networks in rural communities, reduced costs of mobile handsets, general increase in non-food expenditure and innovative technologies that integrate mobile applications with traditional health service delivery models. mHealth has found applications in treatment compliance, data collection and disease surveillance, health information dissemination, point-of-care support for health workers, health promotion, emergency medical response, as well as drug supply-chain management.
mHealth implementation in Africa has the potential to improve health outcomes in many ways. The portability and ‘always on’ features of mobile phones, along with their increasing capability to carry and transfer data, make them unique for relaying health information. (9) In addition, the functional and structural properties, namely, low start cost, text messaging and flexible data plans make mobile phones attractive for use in healthcare interventions. (10)
In pilot projects across the continent, the short messaging service (SMS) application has been successfully used to remind patients to take drugs and attend appointments. Studies on the use of SMS as a drug use reminder, conducted in Kenya and Uganda, showed improved adherence to antiretroviral therapy (ART) without additional counselling among HIV positive clients. (2)(3) While most of these projects have focused more on infectious disease treatment adherence, chronic disease management applications will become more relevant as epidemiological shifts to chronic disease accelerate on the continent. However, poor or inconsistent access to health services and drug supplies may frustrate mHealth implementation in the context of treatment compliance in some areas; thus, strengthening health systems is important for successful implementation. (10)
mHealth projects that focus on data collection and disease surveillance leverage on mobile phones’ abilities to collect and transmit data in real time. While studies have shown that mobile phones and PDAs are more effective in data collection compared with traditional pen and paper data collection methods, there is very little evidence that they improve health outcomes. (10-13) However, one primary benefit of projects utilising mobile phones’ data gathering and storage capabilities is that they could actually save government money. For instance, they could cut paper and data-entry costs, and cut travel costs for both doctors and patients. However, it must be noted that mHealth projects such as these are accompanied by ethical dilemmas related to data ownership and sharing, especially if they involve individual patients’ data.
Health Management Information Systems (HMIS) and Point-of-Care support projects for healthcare workers, utilising mobile technologies, have been piloted across Africa with good results. A pilot project using an SMS and web-based data collection tool that enables health workers at district health centres to submit weekly HMIS reports with a focus on disease outbreaks and essential medicines in Uganda proved successful and is currently being rolled out to the country’s 5,000 health facilities. (8) The success of these projects is hugely important, given the acute shortage of healthcare workers in the continent’s health sectors. However, user-friendliness of mHealth applications is key to its successful implementation, especially as clinicians tend to adapt relatively slowly to the use of information technology. When they need information, many clinicians would prefer to ask colleagues, check their own personal library and search online for information, in that order of preference. (14) Therefore, creating incentives for clinicians to adopt HMIS applications may improve its acceptability among them.
The use of SMS to disseminate health information, and prevention messaging to target specific groups, has also been widely implemented across the continent. However, an understanding of the context and culture of the target groups is important in implementing effective mHealth prevention programmes. It should be noted that certain groups, such as the elderly, may have some difficulties using mobile phones, highlighting the need for projects to be well tailored. Furthermore, accuracy of the health information is vital to the success of such projects.
Despite these successes, challenges remain. A major challenge to the implementation of mHealth on the continent is the lack of standardisation and regulatory frameworks to guide its scale-up. In addition, inadequate monitoring and evaluation and use of meaningful, consistent indicators and rigorous evaluation methods for cost-effectiveness may make it difficult to scale up mHealth interventions. Although there has been a proliferation of mHealth pilot projects across the continent, a large proportion of these projects are unsustainable and often expire once initial funding is exhausted. For example, in Uganda alone there were 23 mHealth initiatives in 2008 and 2009 that did not scale up after the pilot phase. (8) Thus, business models and funding schemes for mHealth need to be reviewed to support the scale-up of effective pilots. Conflicting health systems priorities may also slow down the scale-up of successful mHealth interventions in resource-poor countries.
The healthcare systems of many African countries are constrained by high population growth, high disease burden, inadequate health workforce, widespread rural populations and limited financial resources. (15) mHealth is one innovative and potentially effective solution to overcome these constraints. With mHealth, patients who ordinarily have limited access to healthcare may be able to experience continuity of care even after leaving the doctor’s office, by getting connected with providers through their mobile phones.
However, many successful mHealth pilot projects are never scaled up to regional or national level programmes. This is largely due to a lack of funding and coordination among relevant bodies. Creating sustainable, large-scale mHealth interventions requires collaboration among different stakeholders. National governments, for example, may need to align the regulatory and pricing policy of the telecommunications sector with health policy goals to achieve their mHealth goals. (16) However, it should be noted that mHealth is only an enabler of healthcare delivery and cannot entirely replace the role of healthcare providers. Despite its challenges, mHealth has a role to play in reducing the burden of disease and improving health outcomes, and therefore, it should be given priority by governments and health-focused non-governmental organisations (NGOs) working on the continent.
1. ABI Research. Mobile Subscriber Forecast 2012. Available online at: https://www.abiresearch.com.
2. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, et al. Effects of a mobile phone message service on anti-retroviral treatment adherence in Kenya (WelTel Kenya1): A randomised trial. The Lancet 2010; 376(9755): 1838–45.
3. Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: A cluster randomised trial. The Lancet 2011; 378(9793): 795–803.
4. Istepanian R, Laxminarayan S, Pattichis C (eds) M-Health: Emerging Mobile Health Systems. New York: Springer, 2005.
5. World Health Organization. mHealth: New Horizons for Health through Mobile Technologies’. Global Observatory for eHealth series, Adobe digital edition version, vol. 3. 2003. Available online at: http://www.who.int/goe/publications/goe_mhealth_web.pdf.
6. Labrique A. Opportunities and Challenges for mHealth Strategies in Resource-Limited Settings. Health Informatics Grand Rounds Series, Johns Hopkins University Global mHealth Initiative, 2012. Available online at: http://www.jhumhealth.org.
7. Shields T, Chetley A, Davis J. Improving health, connecting people: The role of ICT in the health sector in developing countries: Summary of online consultations. InfoDev working paper series, 2005. Available online at: http://www.infodev.org/en/Document.486.pdf.
8. Lemaire J. Scaling up mobile health: Elements necessary for the successful scale up of mHealth in developing countries. White paper, 2011. Available online at: http://www.adaorganization.org.
9. Mitchel KJ, Bull S, Kiwanuka J, Ybarra ML. Cell phone usage among adolescents in Uganda: Acceptability for relaying health information. Health Education Research 2011; 26(5): 770–81. Abstract Full text.
10. Earth Institute Center of Global Health and Economic Development Columbia University. Barriers and gaps affecting mHealth in low and middle income countries. Policy white paper, 2010. Available online at: http://cgsd.columbia.edu/files/2012/11/mHealthBarriersWhitePaperFINAL.pdf.
11. Krishnamurthy R, Frolov A, Wolkon A, Vanden Eng J, Hightower A. Application of pre-programmed PDA devices equipped with global GPS to conduct paperless household surveys in rural Mozambique. America Medical Informatics Association Annual Symposium Proceedings 2006; 991. Available online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839572/.
12. Parikh TS, Javid P, Ghosh SKK, Toyama K. Mobile phones and paper documents: Evaluating a new approach for capturing microfinance data in rural India. In Proceedings of the SIGCHI conference on human factors in computing systems, 2006, pp. 551–560. Available online at: http://classes.soe.ucsc.edu/.
13. Patnaik S, Brunskill E, Thies W. Evaluating the Accuracy of Data Collection on Mobile Phones: A Study of Forms, SMS, and Voice. ICTD, 2009. Available online at: http://research.microsoft.com.
14. Research2guidance. Global mHealth developer survey: White paper summary of result. 2011. Available online at: http://www.research2guidance.com.
15. World Health Organization. Global burden of disease: 2004 update. 2008. Available online at: http://www.who.int/healthinfo/global_burden_disease.
16. Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Globalization and Health 2006; 2(9). Available online at: http://www.globalizationandhealth.com/content/2/1/9.
This article originally appeared on Perspectives in Public Health.
Image source: morguefile.com
Over the past decade, Africa has experienced an incredible boom in mobile phone use. In 1998, there were fewer than 4 million mobile subscriptions on the continent, but today, there are more than 800 million subscriptions, and this is projected to reach 1.12 billion subscriptions by 2017. (1) Various studies (2)(3) on pilot projects implemented in Africa support the claim that mobile technologies have the potential to transform the face of healthcare by serving as vehicles for delivering specific health interventions. This form of health service delivery, known as mHealth, is seen as a complementary strategy for strengthening health systems and achieving the health-related Millennium Development Goals (MDGs) in low-income countries.
Defining mHealth
The term mHealth was coined by Professor Robert Istepanian, who described it broadly as the use of ‘emerging mobile communications and network technologies for healthcare’. (4) Essentially, mHealth is the use in medicine and public health of mobile communication devices ‘such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices,’ (5) to ‘enhance access to health information, improve distribution of routine and emergency health services, or provide diagnostic services’. (6)
mHealth platforms operate on the premise that technology integration with the health sector has the potential to improve health outcomes. (7) Today, countries such as Ethiopia, Kenya, Nigeria and South Africa are leading the way in using mHealth solutions for health service delivery, (8) and this is driven by the convergence of a myriad of factors – expanding penetration of mobile networks in rural communities, reduced costs of mobile handsets, general increase in non-food expenditure and innovative technologies that integrate mobile applications with traditional health service delivery models. mHealth has found applications in treatment compliance, data collection and disease surveillance, health information dissemination, point-of-care support for health workers, health promotion, emergency medical response, as well as drug supply-chain management.
Opportunities
mHealth implementation in Africa has the potential to improve health outcomes in many ways. The portability and ‘always on’ features of mobile phones, along with their increasing capability to carry and transfer data, make them unique for relaying health information. (9) In addition, the functional and structural properties, namely, low start cost, text messaging and flexible data plans make mobile phones attractive for use in healthcare interventions. (10)
In pilot projects across the continent, the short messaging service (SMS) application has been successfully used to remind patients to take drugs and attend appointments. Studies on the use of SMS as a drug use reminder, conducted in Kenya and Uganda, showed improved adherence to antiretroviral therapy (ART) without additional counselling among HIV positive clients. (2)(3) While most of these projects have focused more on infectious disease treatment adherence, chronic disease management applications will become more relevant as epidemiological shifts to chronic disease accelerate on the continent. However, poor or inconsistent access to health services and drug supplies may frustrate mHealth implementation in the context of treatment compliance in some areas; thus, strengthening health systems is important for successful implementation. (10)
mHealth projects that focus on data collection and disease surveillance leverage on mobile phones’ abilities to collect and transmit data in real time. While studies have shown that mobile phones and PDAs are more effective in data collection compared with traditional pen and paper data collection methods, there is very little evidence that they improve health outcomes. (10-13) However, one primary benefit of projects utilising mobile phones’ data gathering and storage capabilities is that they could actually save government money. For instance, they could cut paper and data-entry costs, and cut travel costs for both doctors and patients. However, it must be noted that mHealth projects such as these are accompanied by ethical dilemmas related to data ownership and sharing, especially if they involve individual patients’ data.
Health Management Information Systems (HMIS) and Point-of-Care support projects for healthcare workers, utilising mobile technologies, have been piloted across Africa with good results. A pilot project using an SMS and web-based data collection tool that enables health workers at district health centres to submit weekly HMIS reports with a focus on disease outbreaks and essential medicines in Uganda proved successful and is currently being rolled out to the country’s 5,000 health facilities. (8) The success of these projects is hugely important, given the acute shortage of healthcare workers in the continent’s health sectors. However, user-friendliness of mHealth applications is key to its successful implementation, especially as clinicians tend to adapt relatively slowly to the use of information technology. When they need information, many clinicians would prefer to ask colleagues, check their own personal library and search online for information, in that order of preference. (14) Therefore, creating incentives for clinicians to adopt HMIS applications may improve its acceptability among them.
The use of SMS to disseminate health information, and prevention messaging to target specific groups, has also been widely implemented across the continent. However, an understanding of the context and culture of the target groups is important in implementing effective mHealth prevention programmes. It should be noted that certain groups, such as the elderly, may have some difficulties using mobile phones, highlighting the need for projects to be well tailored. Furthermore, accuracy of the health information is vital to the success of such projects.
Challenges
Despite these successes, challenges remain. A major challenge to the implementation of mHealth on the continent is the lack of standardisation and regulatory frameworks to guide its scale-up. In addition, inadequate monitoring and evaluation and use of meaningful, consistent indicators and rigorous evaluation methods for cost-effectiveness may make it difficult to scale up mHealth interventions. Although there has been a proliferation of mHealth pilot projects across the continent, a large proportion of these projects are unsustainable and often expire once initial funding is exhausted. For example, in Uganda alone there were 23 mHealth initiatives in 2008 and 2009 that did not scale up after the pilot phase. (8) Thus, business models and funding schemes for mHealth need to be reviewed to support the scale-up of effective pilots. Conflicting health systems priorities may also slow down the scale-up of successful mHealth interventions in resource-poor countries.
Conclusion
The healthcare systems of many African countries are constrained by high population growth, high disease burden, inadequate health workforce, widespread rural populations and limited financial resources. (15) mHealth is one innovative and potentially effective solution to overcome these constraints. With mHealth, patients who ordinarily have limited access to healthcare may be able to experience continuity of care even after leaving the doctor’s office, by getting connected with providers through their mobile phones.
However, many successful mHealth pilot projects are never scaled up to regional or national level programmes. This is largely due to a lack of funding and coordination among relevant bodies. Creating sustainable, large-scale mHealth interventions requires collaboration among different stakeholders. National governments, for example, may need to align the regulatory and pricing policy of the telecommunications sector with health policy goals to achieve their mHealth goals. (16) However, it should be noted that mHealth is only an enabler of healthcare delivery and cannot entirely replace the role of healthcare providers. Despite its challenges, mHealth has a role to play in reducing the burden of disease and improving health outcomes, and therefore, it should be given priority by governments and health-focused non-governmental organisations (NGOs) working on the continent.
References
1. ABI Research. Mobile Subscriber Forecast 2012. Available online at: https://www.abiresearch.com.
2. Lester RT, Ritvo P, Mills EJ, Kariri A, Karanja S, Chung MH, et al. Effects of a mobile phone message service on anti-retroviral treatment adherence in Kenya (WelTel Kenya1): A randomised trial. The Lancet 2010; 376(9755): 1838–45.
3. Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, et al. The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: A cluster randomised trial. The Lancet 2011; 378(9793): 795–803.
4. Istepanian R, Laxminarayan S, Pattichis C (eds) M-Health: Emerging Mobile Health Systems. New York: Springer, 2005.
5. World Health Organization. mHealth: New Horizons for Health through Mobile Technologies’. Global Observatory for eHealth series, Adobe digital edition version, vol. 3. 2003. Available online at: http://www.who.int/goe/publications/goe_mhealth_web.pdf.
6. Labrique A. Opportunities and Challenges for mHealth Strategies in Resource-Limited Settings. Health Informatics Grand Rounds Series, Johns Hopkins University Global mHealth Initiative, 2012. Available online at: http://www.jhumhealth.org.
7. Shields T, Chetley A, Davis J. Improving health, connecting people: The role of ICT in the health sector in developing countries: Summary of online consultations. InfoDev working paper series, 2005. Available online at: http://www.infodev.org/en/Document.486.pdf.
8. Lemaire J. Scaling up mobile health: Elements necessary for the successful scale up of mHealth in developing countries. White paper, 2011. Available online at: http://www.adaorganization.org.
9. Mitchel KJ, Bull S, Kiwanuka J, Ybarra ML. Cell phone usage among adolescents in Uganda: Acceptability for relaying health information. Health Education Research 2011; 26(5): 770–81. Abstract Full text.
10. Earth Institute Center of Global Health and Economic Development Columbia University. Barriers and gaps affecting mHealth in low and middle income countries. Policy white paper, 2010. Available online at: http://cgsd.columbia.edu/files/2012/11/mHealthBarriersWhitePaperFINAL.pdf.
11. Krishnamurthy R, Frolov A, Wolkon A, Vanden Eng J, Hightower A. Application of pre-programmed PDA devices equipped with global GPS to conduct paperless household surveys in rural Mozambique. America Medical Informatics Association Annual Symposium Proceedings 2006; 991. Available online at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839572/.
12. Parikh TS, Javid P, Ghosh SKK, Toyama K. Mobile phones and paper documents: Evaluating a new approach for capturing microfinance data in rural India. In Proceedings of the SIGCHI conference on human factors in computing systems, 2006, pp. 551–560. Available online at: http://classes.soe.ucsc.edu/.
13. Patnaik S, Brunskill E, Thies W. Evaluating the Accuracy of Data Collection on Mobile Phones: A Study of Forms, SMS, and Voice. ICTD, 2009. Available online at: http://research.microsoft.com.
14. Research2guidance. Global mHealth developer survey: White paper summary of result. 2011. Available online at: http://www.research2guidance.com.
15. World Health Organization. Global burden of disease: 2004 update. 2008. Available online at: http://www.who.int/healthinfo/global_burden_disease.
16. Kaplan WA. Can the ubiquitous power of mobile phones be used to improve health outcomes in developing countries? Globalization and Health 2006; 2(9). Available online at: http://www.globalizationandhealth.com/content/2/1/9.
This article originally appeared on Perspectives in Public Health.
Image source: morguefile.com