The World Health Organization (WHO) defines mHealth as the medical and public health practice supported by mobile devices, such as mobile phones, tablets, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices.
Mobile phones have been used in a wide range of health information and services, in the context of the United Nations Sustainable Development Goals which seek to improve the social, economic and general well-being of people and the planet we live on. mHealth can generate efficiencies and cost savings, and is seen as a solution for major health system challenges in emerging economies: in disease surveillance, supply chain coordination, verification of the genuineness of purchased drugs, mobile telemedicine, health surveys, and raising awareness of healthier behaviours.
Constraints to mHealth initiatives include high costs, poor signal coverage, slow demand generation, inadequate human resources, existing social inequities, and privacy issues. Success factors for effective mHealth innovations include greater awareness of local contexts, effective planning, local participation, sustainable business models, social marketing, stakeholder partnerships, and global knowledge sharing across regions.
Evolution and Scope of mHealth
Entering the world stage only a few decades ago, mobile phones have unexpectedly become ubiquitous. For the first time, there is a form of technology that is owned by both the rich and the poor, according to the UN Health Alliance practitioners Patricia Mechael, Ada Kwan and Dayle Kern. In 2017, analysts estimated the global mHeath market will be worth US$23 billion.
In addition to filling information and communication gaps in health, mobile phones can also be linked to software applications and information systems making data collection and medical record updates possible in real time.
mHealth is a subset of eHealth, which has been defined as the delivery of health-related services via information and communication technologies (ICTs). Another frequently mentioned type of eHealth is telemedicine, which refers to health-related services delivered remotely with clinical participation via electronic communications.
The UN’s Millennium Development Goals (MDGs) were developed in 2001 by the United Nations, reflecting eight goals designed to improve social and economic conditions worldwide by the year 2015. Three of these specifically emphasise the need for improvements in health, and are well suited for process and programme implementations via mobiles:
MDG 4 – To reduce child mortality rates
MDG 5 – To improve maternal health
MDG 6 – To combat HIV/AIDS, malaria, and other diseases
These goals have now been updated with the Sustainable Development Goals (SDGs), with connections to health such as good well being (Goal 3) and clean water (Goal 6).
mHealth Activities and Impacts
In numerous cases, mobiles are capable of delivering accurate information to individuals. They can improve awareness and education of a health topic and then contribute to modifying routines to accommodate healthier attitudes and behaviours. Education and awareness campaigns – important components in comprehensive health programmes – are one of the centerpieces of public health. Providing this information via mobile phones is a new and direct channel for public health campaigns.
In place of traditional paper-based reports delivered by hand, newer methods exploit mobile devices for remote data collection via software and applications which can transmit data synchronously or asynchronously to servers for easy and real-time analysis. This saves time and transportation costs while improving data availability and accuracy. This is an attractive option in many cases where there are data gaps about mortality, malnutrition, disease outbreaks, and other public health issues.
Mobiles can also be used for remote monitoring of patients from the field and sending health reports with information about events and treatment gaps across wireless networks to servers linked to the health system. An instance would be diabetes indicator measurements.
mHealth communication strategies are also being employed to assist health workers with their responsibilities and professional development – from those that facilitate general communication interactions and networking to more complicated strategies in the form of decision-making support and learning.
In mHealth activities for diagnosis and treatment support, both health workers and patients are being targeted as end users. For health workers, materials accessible on – or downloadable to – mobile phones can be used during care either at health facilities or during home visits and other outreach. Mobile technologies are being used for community case management of health conditions to enable early detection, referral, and follow-up for conditions such as pregnancy, malnutrition, and malaria.
For disease surveillance, such as disease and epidemic outbreak tracking, mobile phone software and applications are providing a wireless option to send relevant data on disease incidence, outbreaks, and the geographic spread of public health emergencies. Because of global positioning systems (GPS), the mobile phone data can be localised and mapped for visualisation.
In many parts of the world, medication stockouts can have fatal effects. By using mobile phones in supply chain management and verification, delivery systems can be improved and stockouts avoided. In addition, in areas where counterfeit medications are a problem, mobile phones can be used to verify the authenticity of a drug to ensure safety.
At the back-end, the collection and transmission of information from the communities to data centres in health administrative systems at key points across health systems are beginning to rely less on paper-based methods and more on mobile devices and wireless connectivity. This provides a platform for prioritisation of health objectives and more accurate budgeting.
However, not all mHealth interventions are successful, and many projects are short-lived. The lesson here is that when the intended beneficiaries do not see the value of the mHealth integration, both the idea and the hardware are soon soon abandoned.. It is important to note that mobile technologies should not be considered a fix-all, but instead a tool with the ability to catalyse solutions for pressing issues.
At the implementation level, constraints mentioned include costs, poor signal coverage (particularly in rural areas), and resulting increases in demand for services which cannot be met due to the strain on human resources. There is also a lack of effective business models for sustainable demand generation in many cases. Together, effective business models, coupled with monitoring and evaluation and supportive policy and regulation will enable meaningful scale up and commercialisation of mHealth, but the current lack of these elements in the landscape hinders mHealth growth.
There are also unresolved issues of confidentiality, privacy, and security: without regulations or set boundaries, health information being sent on mobile phones across wireless networks can result in serious repercussions in the form of violation of patients’ rights. There needs to be stronger government commitments in policy and regulation.
mHealth in India
A number of mHealth implementations have been created or replicated in India; some of them have also been highlighted in the Vodafone-YourStory mHealth showcase. For example, the Arogya mDiabetes programme is aimed at behaviour change to prevent diabetes. India is the world’s capital for diabetes, and a range of other diseases. More than 20 percent of Indians have at least one chronic disease. India has 50 million diabetes patients, with over 1 million deaths per year that could be attributed to the disease, according to Sandhya Ramalingam, programme evaluation head at Arogya World.
The HealthPhone datacards pre-loaded with healthcare content for mothers are designed to address the pitiful situation of India having the largest number of first-day deaths of babies in the world (followed by Nigeria, Pakistan, China, DR Congo), according to Nand Wadhwani of the Mother&Child Health and Education Trust in Mumbai.
HealthPhone is a personal library of educative images, audios and videos on a micro-card for use on any smartphone. Content partners include UNICEF, Riddhi and the National Rural Health Mission. The video content is available in 50 languages, including 15 Indian languages. This educational material helps reduce dependency on training and resource institutions.
The CommCare service developed by Dimagi Health Solutions (NEEDS) in Jharkhand also enables information sharing between community health workers to reduce neo-natal deaths. The MfM (Mobilefor Mother) app in Hindi is used for training, data collection and quick follow-up to resolve errors. The service has helped increase the intake of nutritious food by mothers, and more widespread usage of mosquito nets as a health precaution.
The project Mobile Kunji by BBC Media Action in Bihar also addresses change in maternal behaviours via mobiles. Mobiles are used along with mass media, community mobilisation and inter-personal communication. Rural Bihar has TV penetration of 18 percent radio 11 percent and mobiles 80 percent.In fact, 100 percent of health workers have mobiles. The ‘MobileAcademy’ features lesson modules about health habits, and ‘Mobile Kunji’ consists of a pouch with 40 cue cards on a ring. VAS costs are subsidised by six mobile operators, with a standardised shortcode across all operators.
We all know how elders often forget to take their medication on time. Reminder app services that go beyond alerts and track actual consumption of medicine via response messages are being designed, which will build useful analytics of how often these alerts work, and why patients still don’t or can’t take their medication as advised. Predictive components can take pro-active action for patients who may have problems in getting the medicine on time.
Much attention, understandably, is being given to apps for doctors, patients and pharmacists, but new services can be designed for another crucial part of the medical ecosystem: nurses, for functions such aspatient tracking and medication monitoring. Social networking among nurses can tap their own ‘tacit’ knowledge, and knowledge mobilisation in this community can yield new healthcare insights.
A number of organisations already have databases of blood donors, and social media components can be added to this as well as extensions for organ donation.
The Road Ahead
These and some other examples show that mobiles are a good reinforcement for health programmes as well as for social enterprises on the ground. Mobile usage in India is moving beyond voice and SMS to social networking. “Most Facebook interaction in India is on mobile phones,” said Ankhi Das, Head of Public Policy, Facebook India, speaking during a UNICEF-DEF consultation. The users actively engage the platform for business networking and social mobilisation; the Indian government has also used crowdsourcing to get inputs on rape law changes. Mobiles are clearly the dominant digital tool in India.
“Mobiles are the biggest platform in human history,” according to Anirban Mukerji, senior manager, Qualcomm/Wireless Reach, which supports initiatives such as weather information for fishermen (Fisher Friend in Tamil Nadu) and wireless sensors for cleaner stoves (TERI). Scaling up initiatives across states requires government support, and the Department of IT has come up with a framework of mobile governance (websites, shortcodes, apps, open standards).
“We also need to understand that there is a lot of innovation happening at the grassroots without our knowing it,” observes Arjun Venkatraman of CGNet Swara, ICT4D practitioner in Bhopal.
A number of recommendations and best practices have emerged for ensuring that such social enterprises successfully leverage mobile media: develop clarity on metrics used, conduct deep immersive research into mobile interaction behaviours, aggregate and harmonise multiple sets of data, go hyper-local, cultivate diverse ecosystem partnerships, and focus on the simplicity of design.
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