Also In This Issue

Health Worker Migration: Disease or Symptom?

Greater than the Sum

In-Country Supply Chains

Leadership and Management

Health System’s Levers

The Road Not Taken

The Making of Anatomy of a Pandemic: A PBS Documentary

Are Cell Phones Leading the mHealth Revolution?

Nellie Bristol

 

Health workers are tapping into mobile phones in the developing world as use of the portable handhelds leapfrogs exponentionally over landlines and lagging Internet access.

In fact, cell phone use in developing countries is driving a whole new industry in health-related electronic applications for programs in the most remote areas that range from diagnosis and health worker education to social marketing and the flow of emergency food rations.

Global health and technology experts cite dozens of projects using electronic methods (known as "eHealth") that are increasing data collection opportunities and leveraging meager health care work forces. But the technology explosion is facing many of the same problems as in developed countries: lack of interoperability, funding shortfalls and scant solid evidence of outcomes improvement. It also faces hurdles unique to global health - sustainability, inability to scale, and hardware and infrastructure challenges.

Promising new technologies are being developed, including low-energy use computers that are functional in challenging environments, and solar-generated power sources. But the biggest boon to extending the technology revolution to remote rural areas is coming from an unexpected source and, in something unusual in global health, being driven by the private sector: the explosion of cell phones in the developing world, particularly in Africa.

"I think it took a lot of people by surprise because the cell phone spread so quickly and immediately connected all of these people who were not able to be connected through other ehealth programs," said Karl Brown, associate director of applied technology for the Rockefeller Foundation. Spurred by low-cost handsets and pay-as-you-go airtime purchasing, estimates indicate that 64 percent of all mobile phone users are in the developing world and that a majority of Africans have access to a phone.

"A whole set of technical interactions can be mediated so much better by cell phones than by websites," says Peter Benjamin, general manager of Cell-Life, an HIV-care technology project in South Africa. He notes that 18 percent of clinics in South Africa have connected computers while 96 percent have a least one cell phone. Phones often are connected to a central computer or server, which acts as the hub for the system. In this way, mobile technology "is really a way to strengthen broader eHealth initiatives and to connect what's happening in the field to what's happening in the cities where there is a platform for eHealth infrastructure," said Katrin Verclas, editor and coordinator for MobileActive.org, a group that advocates mobile phone use for social change.

Examples of new cell phone developments include:

• ClickDiagnostics, a Boston-based group that uses smart phones with high-resolution photography to snap photos of skin problems. The image is transmitted to a computer and downloaded on a website accessible by pass code. Participating dermatologists can access the site from anywhere in the world and make a diagnosis. After starting in Egypt, Ghana, Botswana, Bangladesh and Haiti, the group is now conducting projects in a number of other countries and is struggling to keep up with demand for services.
• Cellphones 4 HIV, developed by Cell-Life, offers remote patient monitoring that tracks vital signs and drug adherence. It also is establishing patient support networks and helps build organizational capacity for HIV groups. 
• EpiSurveyor, open source software that allows data collection in remote areas, largely with PDAs, is taking a major step forward this year with a web-based version that will use cell phones as collection devices. Improvements to the system, developed by Washington, D.C.-based DataDyne, will allow surveys to be collected and transmitted in real time to a central administrator.

While enthusiasm is high for the new devices, there are challenges. Among those are financing constraints, lack of connectivity among various systems and devices, and securing local buy-in. Another issue listed as a major barrier by WHO's Global Observatory for eHealth (GOe): lack of language variability. GOe's 2006 study found multi-lingualism and cultural diversity to be "the least developed area of any examined." It adds: "It appears that these issues which directly impact citizen access to information are not high on the current agenda of many governments."

Building scale also is a problem. Warren Kaplan of the Boston University Center for International Health & Development, in a review of mobile health technologies in 2007, found there are a number of pilot projects that involve less than 40 people. "There's a million of these," he said. "The question is can you create a business model and can you adequately scale this stuff up so that it works."

Cell-Life's Benjamin agrees: "There's currently a lot of hype and baskets full of anecdotes and exciting little projects but almost nothing that actually show its use at any sort of scale."

Neal Lesh, strategic director for Dimagi, a Massachusetts-based developing world technology group, describes the current global health technology field as "a thousand flowers blooming." He compares it to early U.S. car development when dozens of models were advanced before the market settled on the few that actually functioned and sold well.

There are efforts to bring some standardization and coordination to the field so that devices and systems can talk to each other and provide a common data set of individual, community and country health information. The UN Foundation, the Vodaphone Foundation, and the Rockefeller Foundation announced in February the launch of a Mobile Health Alliance to join the disparate elements of the growing movement, including manufacturers and operators, NGOs, global governance groups and donors. The alliance aims to limit fragmentation and duplication while building scale and sustainability.

But consultant David Lubinski, formerly with Microsoft and WHO's Health Metrics Network and now working with PATH, warns that while integration is important to advancing electronic technology, the real barrier to larger scale projects is a lack of systems expertise among those involved in the field in that they know only their own projects but not how to develop systems. Applications are developed by narrow programs for their specific purposes but run into the same "silo" driven mindset that afflicts other aspects of global health. Further, he said, many applications are developed starting from the viewpoint of the end user, not the worker in the field.

"Before we worry about plugging all these things together, have we done good design, have we understood the work of a community health worker, have we understood the work of a facility nurse, have we understood the work of a warehouse manager?" Lubinski asked. Without that understanding and with continued focus on vertical programming, new applications could simply transfer current inefficient, donor-driven paper systems onto high tech devices. "It would be a sad day if, in fact, you saw community health workers carrying two or three different phones because they were designed to work for different ways of collecting health information," he said.

Despite the obstacles, the potential of electronic technologies, particularly the cell phone, has many in the global health community excited. With hopes for better systems, more local expertise and more efficacy research, global health practitioners are aiming for a common goal. "We're trying to see what is the potential for using technology to empower people with information, communication and interactive service to take better care of their health and improve the lives of the people they love," Peter Benjamin said.

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Nellie Bristol is a freelance journalist specializing in health policy.