CURRENT TOPICS & OPINIONS
mHealth in Africa: challenges and opportunities 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 student at the University of Oxford, 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 studies2,3 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 lowincome 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
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 applicaservice delivery,8 and this is driven by the tions will become more relevant as epiconvergence of a myriad of factors – demiological shifts to chronic disease expanding penetration of mobile netaccelerate on the continent. However, works in rural communities, reduced poor or inconsistent access to health costs of mobile handsets, general services and drug supplies may increase in non-food expenditure and frustrate mHealth implementation in innovative technologies that integrate the context of treatment compliance in mobile applications with traditional health some areas; thus, strengthening health service delivery models. mHealth has systems is important for successful found applications in treatment compliimplementation.10 ance, data collection and disease surveilmHealth projects that focus on data lance, health informacollection and distion dissemination, ease surveillance point-of-care support Studies on the use of leverage on for health workers, mobile phones’ SMS as a drug use health promotion, reminder, conducted in abilities to collect emergency medical and transmit data Kenya and Uganda, response, as well as in real time. While showed improved drug supply-chain studies have adherence to management. shown that mobile phones and PDAs antiretroviral therapy are more effective OPPORTUNITIES (ART) in data collection mHealth implementacompared with tion in Africa has the traditional pen and paper data collection potential to improve health outcomes in methods, there is very little evidence that many ways. The portability and ‘always on’ features of mobile phones, along with they improve health outcomes.10–13 However, one primary benefit of projects their increasing capability to carry and utilising mobile phones’ data gathering transfer data, make them unique for and storage capabilities is that they could relaying health information.9 In addition, actually save government money. For the functional and structural properties, instance, they could cut paper and datanamely, low start cost, text messaging entry costs, and cut travel costs for both and flexible data plans make mobile doctors and patients. However, it must be phones attractive for use in healthcare noted that mHealth projects such as interventions.10 these are accompanied by ethical dilemIn pilot projects across the continent, the short messaging service (SMS) appli- mas related to data ownership and sharing, especially if they involve individual cation has been successfully used to remind patients to take drugs and attend patients’ data. Health Management Information appointments. Studies on the use of SMS as a drug use reminder, conducted Systems (HMIS) and Point-of-Care in Kenya and Uganda, showed improved support projects for healthcare workers,
14 Perspectives in Public Health l January 2014 Vol 134 No 1
Copyright © Royal Society for Public Health 2013 SAGE Publications Downloaded from rsh.sagepub.com at UNIVERSITE DE MONTREAL onISSN June 7, 2015 1757-9139 DOI: 10.1177/1757913913514703
CURRENT TOPICS & OPINIONS utilising mobile technologies, have been piloted across Africa with good results. A pilot project using an SMS and webbased 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 scaleup. 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, inad-
equate 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 (Last accessed 5th April 2013). 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 and 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 (Last accessed 7th May 2013). 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 (Last accessed 8th May 2013).
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 (Last accessed 7th June 2013). 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 (Last accessed 5th June 2013). 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. 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 (Last accessed 8th July 2013). 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/ (Last accessed 4th June 2013). 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/ (Last accessed 5th June 2013). 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 (Last accessed 8th June 2013). 14. Research2guidance. Global mHealth developer survey: White paper summary of result. 2011. Available online at: http://www.research2guidance.com (Last accessed 7th June 2013). 15. World Health Organization. Global burden of disease: 2004 update. 2008. Available online at: http://www.who.int/healthinfo/global_ burden_disease (Last accessed 7th June 2013). 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 (Last accessed 7th June 2013).
January 2014 Vol 134 No 1 l Perspectives in Public Health 15 Downloaded from rsh.sagepub.com at UNIVERSITE DE MONTREAL on June 7, 2015
mHealth in Africa: challenges and opportunities 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 student at the University of Oxford, 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 studies2,3 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 lowincome 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
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 applicaservice delivery,8 and this is driven by the tions will become more relevant as epiconvergence of a myriad of factors – demiological shifts to chronic disease expanding penetration of mobile netaccelerate on the continent. However, works in rural communities, reduced poor or inconsistent access to health costs of mobile handsets, general services and drug supplies may increase in non-food expenditure and frustrate mHealth implementation in innovative technologies that integrate the context of treatment compliance in mobile applications with traditional health some areas; thus, strengthening health service delivery models. mHealth has systems is important for successful found applications in treatment compliimplementation.10 ance, data collection and disease surveilmHealth projects that focus on data lance, health informacollection and distion dissemination, ease surveillance point-of-care support Studies on the use of leverage on for health workers, mobile phones’ SMS as a drug use health promotion, reminder, conducted in abilities to collect emergency medical and transmit data Kenya and Uganda, response, as well as in real time. While showed improved drug supply-chain studies have adherence to management. shown that mobile phones and PDAs antiretroviral therapy are more effective OPPORTUNITIES (ART) in data collection mHealth implementacompared with tion in Africa has the traditional pen and paper data collection potential to improve health outcomes in methods, there is very little evidence that many ways. The portability and ‘always on’ features of mobile phones, along with they improve health outcomes.10–13 However, one primary benefit of projects their increasing capability to carry and utilising mobile phones’ data gathering transfer data, make them unique for and storage capabilities is that they could relaying health information.9 In addition, actually save government money. For the functional and structural properties, instance, they could cut paper and datanamely, low start cost, text messaging entry costs, and cut travel costs for both and flexible data plans make mobile doctors and patients. However, it must be phones attractive for use in healthcare noted that mHealth projects such as interventions.10 these are accompanied by ethical dilemIn pilot projects across the continent, the short messaging service (SMS) appli- mas related to data ownership and sharing, especially if they involve individual cation has been successfully used to remind patients to take drugs and attend patients’ data. Health Management Information appointments. Studies on the use of SMS as a drug use reminder, conducted Systems (HMIS) and Point-of-Care in Kenya and Uganda, showed improved support projects for healthcare workers,
14 Perspectives in Public Health l January 2014 Vol 134 No 1
Copyright © Royal Society for Public Health 2013 SAGE Publications Downloaded from rsh.sagepub.com at UNIVERSITE DE MONTREAL onISSN June 7, 2015 1757-9139 DOI: 10.1177/1757913913514703
CURRENT TOPICS & OPINIONS utilising mobile technologies, have been piloted across Africa with good results. A pilot project using an SMS and webbased 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 scaleup. 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, inad-
equate 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 (Last accessed 5th April 2013). 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 and 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 (Last accessed 7th May 2013). 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 (Last accessed 8th May 2013).
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 (Last accessed 7th June 2013). 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 (Last accessed 5th June 2013). 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. 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 (Last accessed 8th July 2013). 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/ (Last accessed 4th June 2013). 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/ (Last accessed 5th June 2013). 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 (Last accessed 8th June 2013). 14. Research2guidance. Global mHealth developer survey: White paper summary of result. 2011. Available online at: http://www.research2guidance.com (Last accessed 7th June 2013). 15. World Health Organization. Global burden of disease: 2004 update. 2008. Available online at: http://www.who.int/healthinfo/global_ burden_disease (Last accessed 7th June 2013). 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 (Last accessed 7th June 2013).
January 2014 Vol 134 No 1 l Perspectives in Public Health 15 Downloaded from rsh.sagepub.com at UNIVERSITE DE MONTREAL on June 7, 2015
