MobileActive.org

Despite the strong promise demonstrated by mHealth tools and applications, the current landscape of mHealth development in developing country contexts is characterized by a proliferation of unsustainable pilot projects that 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. In India, there were over 30 mHealth initiatives in 2009 that did not go beyond the pilot phase.

Current policy environments, business models and funding schemes around mHealth have fueled the proliferation of pilot projects without enabling them to scale up in a meaningful, replicable way. An additional, and perhaps most significant, obstacle to improving and scaling the implementation of mHealth initiatives is the lack of monitoring and evaluation (M&E) and use of meaningful, consistent indicators and rigorous evaluation methods.

Given the obstacles within the current landscape, this white paper was commissioned by Advanced Development for Africa (ADA) to assess current implementations of successful mHealth programs in developing country contexts. The objective is to identify elements necessary for successfully scaling up, with the aim of highlighting best practices and specific programmatic, operational, policy and global strategy recommendations that can promote scale up of mHealth.

Profiled in this report are several select mHealth programs that have been piloted and are currently in the scale up phase, and have proven enough success that they should be considered as models for other initiatives to follow. As the following case studies will demonstrate, through more accurate and timely data, disease surveillance, decision support and health information management, mHealth can effectively inform policy-making and planning within healthcare systems and improve the health of local communities, particularly remote populations. The scale up of mHealth within national health agendas should be supported by all departments within the Ministry of Health and across other relevant ministries and agencies including Telecommunications. Both internal stakeholders, such as end-users and beneficiaries, and external stakeholders, such as mobile network operators and donors, should be engaged in the planning and business model design and scalability assessments. The primary goal of this white paper is to provide evidence and recommendations that will allow mHealth initiatives to better plan their own scale up beyond successful pilot phases.

USAID‘s Strengthening Health Outcomes through the Private Sector (SHOPS) project seeks to increase the role of the private sector in the sustainable provision and use of quality family planning/reproductive health and other health products and services. One of the areas of technical focus of the SHOPS project is to identify, deploy, and scale up promising uses of mobile technologies to improve health outcomes. Many developing countries have a severe shortage of health providers, and many of the providers who are working have only limited access to up-to-date clinical protocols, or face-to-face trainings. Mobile phones offer an innovative channel through which to provide cost-effective approaches for clinical training and support for improving quality of care.

SHOPS‘ partners Abt Associates, Jhpiego, and Marie Stopes International (MSI), collaborated in a mobile learning and performance support pilot called Mobiles for Quality Improvement (m4QI) conducted in Uganda during the period September 2010–August 2011. The goal of m4QI was to demonstrate the potential for positive behavioral change in service delivery by reinforcing face-to-face induction training lessons provided to Marie Stopes staff. Research supports the theory that spaced reinforcement of training combined with testing can significantly improve long-term knowledge retention and facilitate behavioral change.

The objectives of m4QI were to develop and test a technology-supported approach to performance improvement including processes for identifying performance gaps in adherence to clinical protocols, a platform to manage and automate the delivery and receipt of text message reminders and quizzes to address the gaps, and production of actionable data to improve effectiveness of supportive supervision and follow-up. To support scalability and replicability, the pilot platform was designed for users of low-end phones, and those without Internet access.

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.

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.

Access to basic health  service is limited in rural areas of Bangladesh, where 80% of the total population lives. For instance, 35% of doctors and 30% of nurses are located in four metropolitan districts where only 14.5% of the population lives. Most of the rural people are physically removed from qualified health care providers. Two major mobile phone service providers in Bangladesh have initiated mobile health care help line services nationwide as a remedy to this situation.

Since there is much hope of mobile phones to be used for basic health care services for populations living in rural areas, this research aims to evaluate how far such interventions reached  for the improvement of health care in those communities. Through an interpretive case-based research strategy, our field studies uncover enthusiasm from the rural people towards availing health help line services and the intervention's contribution to improved health-seeking behavior.

This report takes a journalistic rather than an academic approach. It aims to pique interest, provoke debate, and explore the ideas that emerged from a groundbreaking relationship. It also hopes both to accentuate the Technology Partnership’s many positive results while providing a sense of self-reflection that might benefit other potential partnerships.
Over half a decade of experimentation, the Technology Partnership encountered many challenges and saw a variety of outcomes – some successful, others less so. Some of those outcomes might have been improved by different design, but many were also an unavoidable consequence of a complex world of many players and the fast rate of
technological change.

What emerges clearly, however, is a moment of extraordinary and continued opportunity in which both the humanism of the UN and the action-oriented culture of the private sector will be essential. The potential of this cross-sector collaboration is demonstrated by the work of the UN Foundation and Vodafone Foundation. Public-private alliances of this kind require sacrifice and hard work but promise a significant boost to global efforts to improve human wellbeing.

Uganda suffers from a severe shortage of professional healthcare workers. Thus, programs aimed at prevention of disease are an important complement to the limited healthcare delivery system.

We analyze two deployments of an SMS-based HIV/AIDS education system that uses a quiz format to assess people’s knowledge of the disease, including its causes and methods of prevention. The deployments were to two groups in Uganda, one a sample of mobile phone users who live in a town in northwest Uganda; the other, workers at three factories in central and southeastern Uganda. The two samples had accuracy rates above chance levels and workers at the three factories had higher rates of participation (more individuals and more questions) than the sample selected from the cell tower service area. An analysis of incorrect answers suggested that while participants had some difficulty in matching the formatting required by the quiz, literacy did not appear to be a significant problem.

We discuss the results in terms of implications for using SMS as a user interface mechanism and explore the possibility of using social ties among participants as a way to promote the scalability and sustainability of this quiz-based education method.

Still in its infancy, mHealth, the use of mobile technologies for health, runs the risk of not realizing its full potential due to small-scale implementations and pilot projects with limited reach. To help shed light on these issues, the mHealth Alliance commissioned an in-depth exploration of the policy barriers and research gaps facing mHealth. The review identified significant gaps in mHealth knowledge stemming from the limited scale and scope of mHealth implementation and evaluation, a policy environment that does not link health objectives and related metrics to available mHealth tools and systems, and little investment in cost-benefit studies to assess mHealth value and health outcomes research to assess success factors and weed out poor investments.

As illustrated throughout the literature, the current single-solution focus of mHealth needs to be replaced by using mHealth as an extension and integrator of underlying health information systems along the continuum of care. Creating a strong collaborative foundation will be instrumental in driving and positioning public and private investment in mHealth in a way that contributes to achieving improved access to health information and services, health outcomes, and efficiencies.

Within such structured paradigms, planning for infrastructure investment and human resources capacity strengthening and identifying public and private stakeholders within the ecosystem to take leadership for the development, testing, implementation, and evaluation of mHealth activities can be appropriately mapped and planned and mHealth services more effectively extended to support the health of citizens and the work of health professionals and administrators.

Rural health workers in India do not always have the training, credibility or motivation to effectively convince clients to adopt healthy practices. To help build their efficacy, we provided them with messages on mobile phones to present to clients. We present a study which compared three presentations of persuasive health messages by health workers using a phonebased lecture-style message, a phone-based dialogic message that elicits user responses, or no additional aids.

We found that dialogic messages significantly improve the quality of counseling sessions and increase discussion between health workers and clients; however, we did not statistically measure an effect of either phone-based message on health behavioral outcomes. We analyze these results in light of the challenges we faced and compromises we made through the research process due to the interplay of social, cultural and environmental realities, and discuss how these factors affect ICTD projects at large.

Patient data collection and emergency health service is the primary challenge in developing countries. Risk assessment of pregnant mother and healthcare based on priority is almost impossible in present health service of Bangladesh.

A pilot study was done in three urban slums of Dhaka where BRAC health workers were provided with mobiles. A smart algorithm was incorporated in the mobiles. The mobile solution came up with useful findings. The health workers now could send data directly to central MIS system which reduced previous time lag. A secure web page contained all the patient data which was accessible by BRAC Personnel from anywhere any time. An automated risk assessing decision tree categorized the patients depending on their risk levels for timely treatment.

The mobile solution proposed a pro-active, cost-effective platform for rapid health service for pregnant mothers and neonates with reduced manpower.

This guide provides an inexpensive way to create an SMS communications network to enable healthcare field workers as they serve communities and their patients. The steps are purposefully simple – the system is easy to set up, use and maintain.

Answers to Frequently Asked Questions:

1. Who might benefit from a text-based communications network?
2. What are the benefits for my hospital, clinic or organization and the people it serves?
3. What technology do I need?
4. Do I need an internet connection?
5. How expensive is an SMS network?
6. How do I distribute communication credit?
7. How much staff training is required?
8. How much time does it take, per day, to manage the SMS network?
9. How do I conduct SMS training?
10. What is the best power source for the cell phones?
11. Do the CHWs communicate with each other?
12. Where can I find more information on FrontlineSMS?

This White Paper, written by a team of researchers at the Center for Global Health and Economic Development at the Earth Institute, Columbia University, examines and synthesizes the existing mHealth literature to assess the current state of mHealth knowledge, evaluate the impact of mHealth implementations in LMICs and to examine programming, policy and research-related barriers to and gaps in mHealth scale and sustainability.

The paper is divided into two main sections. The first section reviews and summarizes the peer-reviewed literature on mHealth initiatives (focus on LMICS) to highlight trends and challenges. The second section examines the existing mHealth policy environment, barriers and gaps, and key drivers needed for an enabling policy environment.

The major thematic areas include:

• Treatment Compliance
• Data Collection and Disease Surveillance
• Health Information Systems and Point of Care Support
• Health Promotion and Disease Prevention
• Emergency Medical Response

The review identified significant gaps in mHealth knowledge stemming from the limited scale and scope of mHealth implementation and evaluation, a policy environment that does not link health objectives and related metrics to available mHealth tools and systems, and little investment in cost-benefit studies to assess mHealth value and health outcomes research to assess success factors and weed out poor investments.

The aim of this paper is to encourage reflection and discussion around the
potential of mHealth in developing countries and to consider how early experiences
can inform the way forward. Toward this aim, I synthesize many reviews and
presentations from the eight years I have been studying the evolution of mobile
phones and health in developing countries. I include observations and discussions
that are now shaping the creation of mHealth as a field, to highlight the ingredients
we need to move from a series of pilot projects and isolated business opportunities
to a full-scale maximization of health-related benefits.

I begin by reviewing the strategic priorities within global health, where mobile
telephony can have the greatest impact, along with organic health-related uses of
mobile phones, and examples of formal mHealth interventions. I then demonstrate
the potential for mobile phones to become an extension and an integral
component of eHealth, describing how information and communication technology
(ICT) can be used in health care, as well as mHealth, as a subset of mServices:
using mobile devices to deliver services such as banking and health. I also show
how trends and interests are converging among key stakeholders within the
mHealth ecosystem, thus forming a foundation on which we can scale up and sustain
more and better mHealth activities. Finally, I present some tactical guidance
for a way forward that will further the objectives of both public health and business,
particularly in outreach efforts to emerging markets, the bottom of the pyramid,
and the next billion mobile phone subscribers.

Mobile phone text messaging is a potentially powerful tool for behavior change because it is widely available, inexpensive, and instant.

This systematic review provides an overview of behavior change interventions for disease management and prevention delivered through text messaging. Evidence on behavior change and clinical outcomes was compiled from randomized or quasi-experimental controlled trials of text message interventions published in peer-reviewed journals by June 2009. Only those interventions using text message as the primary mode of communication were included. Study quality was assessed by using a standardized measure. Seventeen articles representing 12 studies (5 disease prevention and 7 disease management) were included. Intervention length ranged from 3 months to 12 months, none had long-term follow-up, and message frequency varied.

Of 9 sufficiently powered studies, 8 found evidence to support text messaging as a tool for behavior change. Effects exist across age, minority status, and nationality. Nine countries are represented in this review, but it is problematic that only one is a developing country, given potential benefits of such a widely accessible, relatively inexpensive tool for health behavior change.

Methodological issues and gaps in the literature are highlighted, and recommendations for future studies are provided. 

The number of mobile phone subscriptions has increased by approximately one billion between the end of 2007 and the end of 2008 (ITU, 2009).  At the beginning of 2009, the number has surpassed four billion.  With this, the use of mobile phones and networks in the mobile health has become increasingly popular in low- and middle-income countries, including Ghana where a broad range of mHealth initiatives are now being implemented. 

This offers many opportunities to translate information and communications technology into gains, particularly for fighting disease and improving population health.  This mHealth Ethnography serves as a critical entry point to both assess the initial state of information, communication, and mobile phone use for maternal and newborn health both within the health sector and the general population in the Dangme West District in the Greater Accra Region of Ghana. 

Key study findings illustrate that there is a strong foundation upon which the MoTECH Project can build to advance the use of mobile telephony to support the achievement of the Millennium Development Goals for health.  These can be divided into two broad categories – those within the health sector and those that extend services to target beneficiaries in the general population. 

With the continued expansion of mobile technology around the globe, and the persistent lack of universal Internet connectivity, the use of mobile phones in public health presents a new opportunity to improve health services delivery. This intersection of mobile technology and public health, known as m-health, offers four distinct applications for international development, including drug adherence and remote monitoring, remote dissemination of information, data collection and disease outbreak surveillance, and diagnostic treatment and support.

Several programs have addressed these m-health applications, but those that are most effective utilize open-source coding, are not reliant upon the Internet, and have great potential for scalability.