As the hugely popular augmented reality game app Pokemon Go excites techies and Luddites alike, it ought to be a reminder of where we are with digital health, and where we aren’t.
I was recently at a future-focused technology event in New York City where I spoke about how useful the instant messaging app WhatsApp was for sharing information and interacting with communities in West Africa during the Ebola crisis. WhatsApp is the most popular chat app in Africa, largely because it is easy to use and can offer a cheaper or free alternative to text messaging.
During the Ebola crisis in 2014-15, WhatsApp gave the BBC special dispensation to use it as a broadcast platform, lifting the limit for a broadcast group beyond its usual cap of 250 people. The BBC set up a subscriber-based Ebola service, posting images, text and audio content from the World Health Organization, the Centers for Disease Control and UNICEF to its 20,000 subscribers, most of whom were in West Africa. At BBC Media Action, the BBC’s international development charity, we took this idea and made localized versions of the service and produced our own content.
How low can you go?
I shared how a big part of the success of the WhatsApp Ebola service was because it was low tech. People from remote and quarantined areas to the national capital could access lifesaving information from an app they already use. The images and audio messages were particularly useful for users with low levels of literacy and accessing the content on basic handsets. It also provided a platform for people to post their questions about routes of transmission and share stories of local solutions.
This gave us a window into what ordinary people were talking about and what rumors were going around. Subscribers would text in or record their questions, and our Sierra Leone office would decide whether the question or myth needed to be addressed on the national radio discussion programs we were also producing. To our surprise, the local service gained 15,000 subscribers in Sierra Leone alone, making it the most scaled use of a chat app during a global health emergency.
At the end of my remarks, an audience member raised his hand and suggested excitedly: “Wouldn’t it be a great idea to use virtual reality headsets to train West African health care workers treating Ebola patients on how to safely wear personal protective equipment?” Hmmm. Had he heard anything I had said about selecting appropriate and abundant technology that allows for scale and sustainability?
Virtual reality, or VR, uses devices such as goggles to create a virtual world that users can interact with. This suggested use would require the distribution of hundreds of VR sets to West Africa, and training on how to use them, all at a time when more urgent needs and equipment were needed.
This is not a rare occurrence. In an effort to address global health challenges, well-meaning professionals, often from advanced economies, too often suggest digital inputs that aren’t well thought through. There is a temptation to get caught up in what the technology can do and forget about basic development principles of community-led solutions or consultation. Not enough effort is made to look to what has worked, namely those digital innovations that have achieved beneficial health outcomes and, importantly, scale and sustainability.
The WhatsApp example demonstrates a simple use of a low tech health information service. There are others that take the same principle of user-centered design and selecting abundant technology, but do more than just share information.
In India we developed mobile services for health workers focused on maternal, newborn and child health. These include job aids accessible from mobile phones to help community health workers effectively counsel families during their household visits and a mobile phone-accessible academy for health workers. Again, the key to the mass uptake of these mobile health services was that we chose to use the mobile handsets the health workers already own.
Content was developed using interactive voice response so that it can be accessed from any basic handset and requires little training and support because accessing the IVR content is as easy as making a phone call.
These decisions allow for easy uptake and scale. To date, nearly 373,000 unique users have accessed over 43 million minutes of content. These usage figures demonstrate that community health workers have integrated our mobile health services into their routine work practice. These services have now been adopted by the government of India and once further scaled, will reach 1 million health workers who counsel almost 10 million women across India.
Certainly the more complex the digital health service, the more advanced the technology and programmatic inputs need to be. Basic handsets can be used to provide information, collect non-sensitive data and train and equip health workers.
For more clinical applications, such as remote diagnosis, digitizing health records and linking services to payments, advanced handsets such as smartphones or feature phones are needed, with specialized software loaded on to them, along with all of the training and distribution implications these require. Using mobile phones for data collection and providing clinical services is further complicated by data protection and privacy issues and thus these demand more complex technical considerations. By their nature, the digital health interventions that require advanced devices and training are more difficult to afford, scale and sustain.
The axiom of design thinking should apply even with ambitious digital health technologies, where the user should be at the center of the idea. Digital health must respond to the needs of the target group, whether that is the general public, health care workers or health system administrators. Detailed research is central to the planning and delivery of such technologies. This research is critical to the selection of appropriate technology, content format (for example audio versus text) and the development of sustainable business models.
One of the legacies of Pokemon Go will be that it introduced augmented reality to the mainstream. Augmented reality allows people to use their smart-device camera to interact with virtual content, such as animated characters, in the real world. Pokemon Go has demonstrated that people are excited to learn new things, provided they have the basic tools necessary to access the new technology and the content is good. The impressive uptake data of tens of millions of users in the first week suggests that Pokemon Go players use the devices they already own. It’s also shown how augmented reality has had greater mass appeal than virtual reality. Again, this may be attributed to the fact that users can use their own device rather than having to acquire or borrow VR-enabled devices.
As exciting as smart-device apps can be, let’s remember to have a reality check. In less developed countries, high-tech digital health initiatives will most certainly mean a small and select user base, along with the ongoing challenges of maintenance and attracting external funding.
These considerations should not quell our imagination however. As a leader in technology innovation once put it to me: “The tyranny of today should not stymie the thinking about tomorrow.” Agreed. But let’s strike a healthy balance between imagination and reality, and not quite the augmented or virtual kind.
Wired for Impact is an online conversation with Novartis Foundation and Devex to explore how to integrate digital health into global development in a way that is scalable and sustainable, and improves the overall quality of health care delivery to build essential connections between patients, health facilities, health providers and policymakers. Tag #Wired4Impact and @Devex to join the conversation.