The Elusive Power of mHealth

Update (December 6): This week, members of the health community are gathering at the third annual mHealth Summit in Washington, D.C., to explore ways to advance mobile technologies for health.  The summit will focus on the business and policy perspectives of mHealth, aiming to identify sustainable business models to support mHealth around the globe.  Below, Amanda Glassman and Vicky Hausman highlight key actions major global health donors should take to help realize the potential of mHealth and move to scalable and sustainable integration of mobile into healthcare delivery.This blog is co-authored with Vicky Hausman, Dalberg Global Development Advisors. These days it seems like everyone is going mobile.  The idea of using mobile phones to deliver health care products, treatments and services has captured the imaginations of everyone from academic experts, government officials and funders of aid to technology companies, innovators and entrepreneurs. There is no shortage of conferences, webinars or tweets on the topic, nor is there a lack of innovative applications and technology.But what is the reality?  Has mHealth really begun to transform health systems?The global health community has come to appreciate the potential of mHealth: it can dramatically extend the reach and touch of health systems, and transform the way in which individuals can receive real-time public health information, manage their own care, and hold service providers or funders accountable.  And indeed, there are certainly pockets of success.  Results of a randomized controlled trial recently published in The Lancet show that WelTel, a mobile-based mechanism for increasing adherence to antiretroviral therapy (ART) for HIV/AIDS, can significantly suppress viral loads.   Episurveyor, which provided mobile software for collecting medical data, and other programs in the non-profit and for-profit sectors have built scalable and replicable models in line with the market’s needs.  And quite a few models are being brought into the mainstream of health systems, from the Clinton Health Access Initiative’s SMS printers for diagnostic data (currently being rolled out across Nigeria) to Rwanda’s mUbuzima program for improving the efficiency of community health workers.Yet despite these successes, mHealth remains in its infancy, with many of the characteristics and issues typical of young industries.  The majority of deployments are still small-scale pilots, so much so that it’s been said there are more pilots in mHealth than there are in the US Air Force.   In many of these pilots, the evidence base that would enable decision-making and prioritization for further investment is missing.  Finally, mHealth tools are not always clearly linked to health systems’ needs and priorities, at times leaving solutions in search of a problem rather than products and services designed with end-user preferences and needs in mind.Amidst a flurry of activity in the industry, mHealth investments and initiatives tend to roll out without much coordination across funders and implementers.  Coordination is important, for example to ensure that community health workers don’t end up bogged down with multiple phones required for different applications associated with individual funding streams.  Institutional alignment on standards and systems can also help health systems to move beyond disease-level or funder-based silos and minimize redundancies.  For example, there are at least seven different mobile-based electronic medical record (EMR) systems used in Kenya, several of which are highly specialized for ART patients.  Though Kenya has endeavored to develop national standards and a way to integrate systems, these efforts have often been challenged by legacy systems and variation in national and donor requirements.  Similarly, there are challenges across vertical funding silos.  For example, PEPFAR’s Health Management Information System, a leader in terms of integrating mobile into relevant health clinic procedures and data management, is limited to capturing patient information related to HIV/AIDS.What this amounts to is a lot of well-intentioned ideas, smaller deployments, and hype – without actually changing the game.  In most developing countries, mobile is not yet integrated into the business processes of healthcare delivery funded by national governments and their external backers.  One illustration of this point is a comparison of global health dollars spent versus investments in mHealth.   While overseas development assistance for global health in 2010 totaled $27B, a bottom-up count of disbursements specifically supporting mHealth (conducted by Dalberg) totaled less than $50 million[1], or less than 0.1% of total spending.In order to realize the potential of mHealth and move to scalable and sustainable integration of mobile into healthcare delivery, global health funders will need to take several actions:

• Invest in the evidence base.  Funders should ensure that each mHealth deployment – including the smallest pilots – has a clearly outlined and funded monitoring and evaluation (M&E) plan which can demonstrate its contribution to health system efficiencies and/or health outcomes.   This is critical to clearly know what works – and what does not.  It is also a key ingredient to maximize return on investment for early-stage initiatives and to inform funding decisions to scale up deployments.

• Align on standards and systems. Standardization would enhance the power of technologies used by health systems and dramatically improve their efficiency.   Avoiding redundant and at times conflicting record keeping will reduce the bureaucratic burden for users and likely increase compliance and the overall value and integrity of the data.  It would also free up health workers’ and administrators’ time. Country decision-makers and other actors have a significant role to play in aligning on standards and streamlining systems.  Funders in turn should ensure their efforts are additive and harmonized with these efforts, where relevant, pushing adherence through the carrots and sticks of financing.

• Ground mobile and information and communications technology (ICT) strategies in country-level realities, needs and opportunities. The availability of technology, the policy environment, and literacy in health and ICT vary widely across countries.  When mobile initiatives are deployed, they should be tied directly to country-level health sector needs and priorities.  Global funders and implementers can tap into the growing number of app labs and innovation hubs cropping up in the developing world to ensure that the technology deployed best meets the on-the-ground reality of users – be they individual patients and consumers of healthcare, health system administrators, doctors or community health care workers.
• Share learnings and best practices. In the next year, the base of knowledge and evidence will grow substantially.  This includes both the results of the M&E mentioned above and lessons about structuring and deploying mobile-based health interventions.  Funders and implementers should share knowledge across these areas, including tactics and terms for negotiating contracts and striking mutually beneficial deals with operators and developers.  Similarly, international funders of global health could increase their engagement with national level stakeholders and emerging ICT working groups to ensure not only global but also national level coordination and knowledge sharing.  MAMA, USAID’s recently launched Mobile Alliance for Maternal Action[2] has been exemplary by prioritizing the creation of evidence and taking an explicitly collaborative approach as it seeks to strengthen the global knowledge base and share best practices for designing mobile health services focused on maternal health.

• Build a coalition of global health funders to improve coordination. There are pockets of activity across most of the major funders– including USAID, PEPFAR, PMI, the Global Fund, GAVI, that would benefit from more formal coordination on these issues of evidence, standardization, interoperability, and overall knowledge sharing.  Bodies such as the mHealth Alliance and more focused working groups such as GreenTree can help to facilitate this coordination, but again, it requires prioritization by the major global health funders.

mHealth’s potential to enable health systems continues to grow with each technological advancement, increase in affordability of smart phones, and intervention to equip health care workers and individuals with the requisite ICT and health literacy to access and appropriately use mHealth tools.   While realizing the potential of mHealth requires actions across the ecosystem players – both globally and at the country level – large scale funders have a clear role to play.   If funders don’t take deliberate steps now to measure outcomes, prioritize investments, and coordinate activities, there is a risk that the current hype will quickly fade and dollars will be directed towards the next big thing.

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[1] Note: illustrative count of funding disbursed based on a literature search and research via publically available announcements. Dalberg research and analysis, 2011.[2] Launched in partnership with J&J, in collaboration with the United Nations Foundation, the mHealth Alliance, and BabyCenter LLC.